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Journal of Preventive Medicine & Public Health

431Copyright © 2021 The Korean Society for Preventive Medicine

Journal of Preventive Medicine & Public Health

PB Copyright © 2021 The Korean Society for Preventive Medicine

J Prev Med Public Health 2021;54:431-440 • https://doi.org/10.3961/jpmph.21.457

Protection Motivation Theory and Rabies Protective Behaviors Among School Students in Chonburi Province, Thailand Mayurin Laorujisawat, Aimutcha Wattanaburanon, Pajaree Abdullakasim, Nipa Maharachpong Faculty of Public Health, Burapha University, Chonburi, Thailand

Original Article

Objectives: The aim of this study was to predict rabies protective behaviors (RPB) based on protection motivation theory (PMT) among

fourth-grade students at schools in Chonburi Province, Thailand.

Methods: This cross-sectional study was conducted from December 2020 to February 2021. A multistage sampling technique was

used for sample selection. The questionnaire was divided into socio-demographic data and questions related to PMT and RPB. De-

scriptive statistical analysis was conducted using the EpiData program and inferential statistics, and the results were tested using the

partial least squares model with a significance level of less than 5%.

Results: In total, 287 subjects were included, of whom 62.4% were girls and 40.4% reported that YouTube was their favorite media

platform. Most participants had good perceived vulnerability, response efficacy, and self efficacy levels related to rabies (43.9, 68.6,

and 73.2%, respectively). However, 54.5% had only fair perceived severity levels related to rabies. Significant positive correlations

were found between RPB and the PMT constructs related to rabies (β, 0.298; p < 0.001), and the school variable (S4) was also a predic- tor of RPB (β, -0.228; p < 0.001). Among the PMT constructs, self efficacy was the strongest predictor of RPB (β, 0.741; p < 0.001). Conclusions: PMT is a useful framework for predicting RPB. Future RPB or prevention/protection intervention studies based on PMT

should focus on improving self efficacy and response efficacy, with a particular focus on teaching students not to intervene with fight-

ing animals. The most influential PMT constructs can be used for designing tools and implementing and evaluating future educational

interventions to prevent rabies in children.

Key words: Rabies, Protective behaviors, Protection motivation theory, Students, Thailand

Received: August 17, 2021 Accepted: October 1, 2021 Corresponding author: Nipa Maharachpong Faculty of Public Health, Burapha University, 169 Long Hard-Bangsaen Road, Tambon Saensuk, Mueang District, Chonburi 20131, Thailand E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by- nc/4.0/) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited.

INTRODUCTION

Rabies is a zoonotic viral disease that affects mammals. Throu- ghout the world, approximately 59 000 people are reported to

pISSN 1975-8375 eISSN 2233-4521

die from rabies every year [1]. Rabies is present on all conti- nents except Antarctica, and over 95% of human deaths from rabies occur in Asia and Africa [2]. Once clinical symptoms be- gin to appear, rabies is almost always fatal [1]. Among zoonot- ic diseases, the significance of rabies as a public health issue is often neglected [2]. In Thailand, rabies is endemic, and, in most cases (93%), dogs are the main reservoir [3]. It is estimated that half a million incursions with mammals that could poten- tially transmit the disease occur annually [4]. The most vulner- able population is children under 15 years of age [4]. From 2011 to 2020, Thailand’s eastern region reported the highest incidence of rabies, contributing 36% of total rabies-related

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deaths in Thailand [3]. In addition, none of the deceased had received any form of treatment [4].

The reason that the most affected group is children under 15 years of age is likely their natural affinity for animals, partic- ularly cats and dogs. Moreover, children generally do not know when they are at risk of rabies. Sometimes children may pro- voke animals to bite them as a consequence of stone-throw- ing, beating, chasing, or running at the sight of the animals [5]. In addition, in some cases, children do not pursue any further treatment after the initial treatment of the wound. In contrast, adults are generally more aware of the risk of rabies and tend to seek medical care [6]. A review of the literature [7-10] found that few children were aware that rabies was a potentially fatal disease and understood that they were vulnerable to the dis- ease. Therefore, awareness and education are key. In addition, the cognitive process plays a key role in decision-making and influencing behavioral changes [11], the factors of which cor- respond to protection motivation theory (PMT).

PMT has been widely adopted as a framework for predicting and influencing health-related behaviors [12]. PMT is based on 2 cognitive processes. The first is threat appraisal (TA), which consists of 2 cognitive aspects—perceived severity (PS) and perceived vulnerability (PV)—and can influence changes in attitudes and behaviors. The second cognitive process is cop- ing appraisal (CA), which also consists of 2 cognitive aspects— response efficacy (RE) and self-efficacy (SE)—and can influ- ence individuals to successfully avoid danger, which is an im- portant factor for making positive behavioral changes. These factors are influenced by fear-inducing media rather than more standard methods of persuasion such as external stimuli, envi- ronmental organization, persuasion, observational learning, personality, and experience [13].

Researchers have used PMT to investigate and understand a wide range of health-related behaviors and preventive/pro- tective behaviors [14-16]. In addition, PMT has been used in etiological studies to investigate various risk behaviors in chil- dren, including tobacco or drug use [17-19], sexual initiation perceptions [20-22], and cybersecurity behavior [23]. Histori- cally, few studies have been conducted examining PMT in the context of rabies prevention, which is one of this study’s main objectives. Moreover, the age of 9 years to 10 years old is a good starting point for providing education related to self- care behaviors [24]. At this age, children are able to develop a thorough understanding of these issues due to their develop- mental stage. Through knowledge and reasoning, children can

develop greater healthcare awareness [25]. Partial least squares structural equation modeling (PLS-SEM)

is one of the most widely used multivariate data analysis meth- ods in the business and social science fields, including in edu- cation, psychology, health, and nursing. It is primarily used to examine models with latent variables [26]. Standard PLS-SEM analyses provide information on the relative importance of constructs for explaining other constructs in a structural mod- el. Information on the importance of constructs is relevant for drawing conclusions. Importance-performance map analysis (IPMA) extends the results of PLS-SEM by also examining the performance of each construct. As a result, conclusions can be drawn across 2 dimensions (both importance and performance), which is particularly important for understanding which man- agerial actions to prioritize [27], and the analysis can be ex- panded to the indicator level to facilitate identification of the most important aspects of specific actions [28]. Due to its sim- plicity and practicality, importance-performance analysis has been popular among researchers and professionals involved in customer satisfaction and quality management for promot- ing efficient resource utilization in various fields, including health [28-30].

This study was conducted to predict the rabies protective behaviors (RPB) of fourth-grade students by applying PMT and using PLS-SEM and IPMA to close an existing gap in the research, with the ultimate aim of improving children’s RPB. Upon the successful completion of PMT analysis, the data can be used to devise targeted rabies prevention programs for elementary school children.

METHODS

Participants and Sampling This cross-sectional study analyzing RPB among fourth-grade

students was conducted from December 2020 to February 2021. It was conducted with the permission of the children and their guardians. The number of participants in this study was calculated with G*Power 3.1 [31] by selecting the F-test with linear multiple regression, a fixed model, and the R2 devi- ation from zero option. The sample size was calculated using a 95% confidence interval (CI) and a 5% error rate. As a result, the sample size was determined to be 270 participants, and we planned for a possible 5% non-response rate. In total, 287 subjects were included. A multistage sampling technique was used for selecting the sample units. The 11 districts in Chon-

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buri Province were divided into 2 strata, with the first consist- ing of 4 districts with a recent history of dogs infected with ra- bies being found in 2020 and the second consisting of 7 dis- tricts with no such history. Three sub-districts were randomly selected from each stratum, for a total of 6 sub-districts. In the second step, 1 school was randomly selected from each sub- district, except for in Nong Samsak, where there were only very small schools. Thus, 2 schools were selected from Nong Samsak, for a total of 7 schools. In the third step, fourth-grade students were randomly sampled using the lottery method. After the data were organized and verified, a total of 287 fourth- grade students were selected from 7 primary schools across 6 sub-districts of Chonburi Province.

Research Instruments A rabies questionnaire was developed based on academi-

cally reviewed information on rabies, PMT, and prevention or protective behaviors among children. The research instrument was a closed-ended questionnaire divided into 3 sections on (1) socio-demographic data, (2) PMT covering 4 areas (PS, PV, RE, and SE), and (3) RPB.

The final version of the questionnaire had an average con- tent validity of more than 0.6, which was calculated using item- objective congruence and indicated adequate content validity. The reliability was measured using Cronbach’s alpha coefficient, which was 0.806 for PMT and 0.773 for RPB in this study.

Statistical Analysis The data collected from the surveys were organized and

verified for completeness and entered into EpiData Analysis version 2.1 (https://www.epidata.dk/). Descriptive statistics were calculated for (1) socio-demographic data, (2) the vari- ables related to PMT, and (3) RPB. The PMT constructs were cat- egorized according to Bloom’s cut-off points (<60 indicating poor, 60-80 indicating fair, and >80% indicating good) [32]. Inferential statistics were tested using PLS-SEM with a signifi- cance level of less than 5%.

Ethics Statement This study was conducted under the highest ethical stan-

dards as outlined by the Burapha University-Institutional Re- view Board for Protection of Human Subject in Research (BUU- IRB), Thailand (#079/2563). The participants’ identifying infor- mation remained confidential throughout.

RESULTS

Socio-demographic Characteristics of the Students

Table 1 shows that a total of 287 fourth-grade students par- ticipated in the study from 7 primary schools across 6 sub-dis- tricts of Chonburi Province. The majority of the participants were girls (62.4%). The proportion of subjects from schools 1 through 7 were 17.8%, 9.4%, 5.2%, 18.5%, 19.9%, 15.3%, and 13.9%, respectively. Among the participants, 50.9% lived in ar- eas where infected dogs were found, and 47.3% of their fa- thers and 38.3% of their mothers reported being self-employed. The most popular media platforms were YouTube (40.4%) and TikTok (36.9%), and 26.5% of the participants reported that they spent between 1 hour and 2 hours per day consuming content on their preferred media platform. A total of 60.3% of the participants had a pet, of which the majority were dogs (42.9%), with an average number of 1.26±2.30 dogs. More than half (53.3%) of the participants had no history of being bitten, scratched, or licked at a wound site by a mammal. Of the participants who reported being injured by a mammal, 34.5% were scratched, 21.3% were bitten, and 3.8% were licked at the wound.

Protection Motivation Theory Constructs and Rabies Protective Behaviors

The PMT construct scores were classified using Bloom’s cut- off points. The data showed that 61.3% of participants had a good level of PMT constructs. When considering each of the aspects of PMT, it was found that the participants had good PV, RE, and SE related to rabies (43.9, 68.6, and 73.2%, respec- tively). Only PS had a fair level, at 54.5%. As shown in Table 2, most of the respondents were unsure that rabies is a fatal dis- ease (60.6%), causes brain damage (65.9%), and typically kills infected animals within 10 days (65.9%). A total of 52.3% of the participants had a good level of RPB; however, 51.9% an- swered that they would not encourage local individuals to an- nually vaccinate their pets (PB1).

Figure 1 and Table 3 present the results of PLS-SEM. Signifi- cant positive correlations were found between RPB and the PMT constructs related to rabies (β, 0.298; standard error [SE], 0.053; p<0.001), and the school, particularly school No. 4 (S4), was a predictor of RPB (β, -0.228; SE, 0.058; p<0.001). Students in S4 had lower RPB scores than students in other schools.

The present study showed that the students perceived that

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the media (β, 0.160; SE, 0.061; p = 0.009) and gender indicators (β, -0.160; SE, 0.066; p = 0.015) were found to be significantly associated with PV, meaning that a preference for YouTube af- fected the PV score more than other media platforms and that

wash the wound with running water and soap several times for at least 15 minutes could mitigate the risk of contracting rabies (PV3), with the PV3 indicator significantly correlating with PMT constructs (β, 0.098; SE, 0.024; p<0.001). In addition,

Characteristics n (%) or mean±SD

Dog and cat 50 (17.4)

Dog and other mammals 3 (1.0)

Dog and cat and other mammals 3 (1.0)

Cat ownership 95 (33.1)

Cat only 42 (14.6)

Cat and dog 50 (17.4)

Cat and other mammals 0 (0.0)

Cat and dog and other mammals 3 (1.0)

Other mammal ownership 14 (4.9)

Other mammals only 8 (2.8)

Other mammals and dog 3 (1.0)

Other mammals and cat 0 (0.0)

Other mammals and dog and cat 3 (1.0)

No. of dogs 1.26±2.30

0 164 (57.1)

1 46 (16.0)

2 29 (10.1)

≥3 48 (16.7)

No. of cats 0.89±2.00

0 192 (66.9)

1 40 (13.9)

2 25 (8.7)

≥3 30 (10.5)

No. of other mammals 0.14±1.50

0 273 (95.1)

1 10 (3.5)

≥2 4 (1.4)

History of animal bites, scratches, or licks at a wound site within the past year

No 153 (53.3)

Yes 134 (46.7)

History of animal bites within the past year

No 226 (78.7)

Yes 61 (21.3)

History of animal scratches within the past year

No 188 (65.5)

Yes 99 (34.5)

History of animal licks at a wound site within the past year

No 276 (96.2)

Yes 11 (3.8)

Table 1. Demographic information

Characteristics n (%) or mean±SD

Gender

Boys 108 (37.6)

Girls 179 (62.4)

School

No. 1 in area 1 51 (17.8)

No. 2 in area 2 27 (9.4)

No. 3 in area 2 15 (5.2)

No. 4 in area 3 53 (18.5)

No. 5 in area 4 57 (19.9)

No. 6 in area 5 44 (15.3)

No. 7 in area 6 40 (13.9)

Residence in an area with rabid dogs

No 141 (49.1)

Yes 146 (50.9)

Father's occupation

Unemployed / stay-at-home father / deceased 21 (7.7)

Employed 70 (25.6)

Self-employed 129 (47.3)

Other 67 (19.4)

Mother's occupation

Unemployed / stay-at-home mother / deceased 49 (17.1)

Employed 61 (21.3)

Self-employed 110 (38.3)

Other 67 (23.3)

Favorite media platform

None 3 (1.1)

YouTube 114 (40.4)

TikTok 104 (36.9)

Other 66 (21.6)

Daily time spent consuming favorite media (hr)

<1 65 (22.6)

≥1 to <2 76 (26.5)

≥2 to <3 60 (20.9)

≥3 to <4 32 (11.1)

≥4 54 (18.8)

Pet ownership (mammal)

No 114 (39.7)

Yes 173 (60.3)

Dog ownership 123 (42.9)

Dog only 67 (23.3)

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scores for PV were higher among girls than boys. There were 2 statistically significant indicators of RE: RE2 (‘I

think that informing parents or people about the annual rabies animal vaccination will help to prevent rabies infection’) and RE4 (‘I think not intervening with animals when they are fight- ing will help to prevent rabies infection’), that the students be- lieved could prevent rabies. These showed significant relation- ships with the other PMT constructs (β, 0.477; SE, 0.019; p<0.001).

Three SE indicators had a statistically significant relationship to PMT constructs (β, 0.741; SE, 0.023; p <0.001), indicating

that students believed they were able to perform those be- haviors to prevent rabies. They were SE2 (‘I am confident that I can reduce my risk of contracting rabies by informing local in- dividuals to vaccinate their pets’), SE3 (‘I am confident that if I immediately inform my teachers/parents after being bitten, scratched, or licked by a mammal, I can reduce my risk of con- tracting rabies’), and SE6 (‘I am confident that if I do not inter- vene with fighting dogs, I can reduce my risk of contracting rabies’). Non-significant relationships were found between PS and the other PMT constructs.

Table 2. Questions related to protection motivation theory and rabies and rabies preventive behaviors

Variables Agree Unsure Disagree

Perceived severity (PS)

PS1: If you have a rabies infection, you will die 65 (22.6) 174 (60.6) 48 (16.7)

PS2: The rabies virus primarily damages the brain 65 (22.6) 189 (65.9) 33 (11.5)

PS3: Dogs and cats who are infected with rabies will perish within 10 d 46 (16.0) 189 (65.9) 52 (18.1)

PS4: If you get bitten and infected by a rabid dog and are not medically treated, you will die 154 (53.7) 104 (36.2) 29 (10.1)

Perceived vulnerability (PV)

PV1: You can get rabies if you play with an unknown dog or cat 95 (33.1) 139 (48.4) 53 (18.5)

PV2: If you get scratched by a cat and immediately tell your parents or teachers, you will have a greater chance of avoiding rabies infection

160 (55.7) 65 (22.6) 62 (21.6)

PV3: If after being bitten you wash the wound with clean water and soap several times for at least 15 min, you will have a greater chance of not contracting a rabies infection

195 (67.9) 61 (21.3) 31 (10.8)

Response efficacy (RE)

RE1: I think that telling a parent or teacher immediately after being scratched by a cat will help to prevent a rabies infection

162 (56.4) 79 (27.5) 46 (16.0)

RE2: I think that informing parents or people about the annual rabies animal vaccination will help to prevent rabies infection

193 (67.2) 75 (26.1) 19 (6.6)

RE3: I think avoiding ownerless cats and dogs is a good method to prevent rabies infection 194 (67.6) 53 (18.5) 40 (13.9)

RE4: I think not intervening with animals when they are fighting will help to prevent rabies infection 200 (69.7) 53 (18.5) 34 (11.8)

Self-efficacy (SE)

SE1: I am confident that if I do not interfere with unknown animals, I will reduce my risk of contracting rabies 208 (72.5) 59 (20.6) 20 (7.0)

SE2: I am confident that I can reduce my risk of contracting rabies by informing local individuals to vaccinate their pets

204 (71.1) 68 (23.7) 15 (5.2)

SE3: I am confident that if I immediately inform my teachers/parents after being bitten, scratched, or licked by a mammal, I can reduce my risk of contracting rabies

237 (82.6) 33 (11.5) 17 (5.90)

SE4: I am confident that if I can identify an animal that scratched me, I can reduce my risk of contracting rabies 70 (24.4) 149 (51.9) 68 (23.7)

SE5: I am confident that if I wash a wound with soap and water for 15 min (WASH15) after being bitten, scratched, or licked by an unknown animal, I can reduce my risk of contracting rabies

171 (59.6) 94 (32.7) 22 (7.7)

SE6: I am confident that if I do not intervene with fighting dogs, I can reduce my risk of contracting rabies 248 (86.4) 21 (7.3) 18 (6.3)

Rabies protective behaviors (PB)

PB1: I will inform local individuals to annually vaccinate their pets 33 (11.5) 105 (36.6) 149 (51.9)

PB2: I will immediately inform teachers/parents if I am bitten or scratched by a mammal even if the wound does not bleed

114 (39.7) 115 (40.1) 58 (20.2)

PB3: I will immediately inform teachers/parents if I witness a friend getting bitten, scratched, or licked at a wound site by a mammal

91 (31.7) 130 (45.3) 66 (23.0)

PB4: I will wash the wound with soap and water (15 min) if I am bitten, scratched, or licked at a wound site by a mammal

87 (30.3) 139 (48.4) 61 (21.3)

Values are presented as number (%).

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Importance Performance Map Analysis IPMA analysis was conducted for the variables that affected

RPB in the initial analysis. IPMA uses a 2-dimensional grid to plot the mean ratings for performance and importance. The x- axis is used to map a variable’s importance, measured by the total effect (0-1), and the y-axis is used to map a variable’s per- formance, based on an adjusted raw score ranging from 0-100 that corresponds to the percentage value. The resulting 4-quad- rant matrix, classified as quadrants A through D (Figure 2), can

be used both to identify opportunities for improvement and to guide strategic planning schemes [33]. Three indicators (RE2: ‘I think that informing parents or people about the annual ra- bies animal vaccination will help to prevent rabies infection,’ SE2: ‘I am confident that I can reduce my risk of contracting ra- bies by informing local individuals to vaccinate their pets,’ and SE6: ‘I am confident that if I do not intervene with fighting dogs, I can reduce my risk of contracting rabies’) were in quadrant A, meaning that RE2, SE2, and SE6 had above-average importance and above-average performance.

There were 2 indicators in quadrant B (PV3: ‘If after being bitten you wash the wound with clean water and soap several times for at least 15 minutes, you will have a greater chance of not contracting a rabies infection,’ and SE3: ‘I am confident that if I immediately inform my teachers/parents after being bitten, scratched, or licked by a mammal, I can reduce my risk of contracting rabies’), meaning that the PV3 and SE3 indica- tors had below-average importance but above-average per- formance. The gender and media indicators were in quadrant C, meaning that they had below-average importance and per- formance. Lastly, RE4 (‘I think not intervening with animals when they are fighting will help to prevent rabies infection’) and S4 were in quadrant D, which had high importance but below-average performance.

Table 3. Detailed measurement and regression results of the structural equation modeling shown in Figure 1

Variables Coefficient SE p-value

Perceived vulnerability

Media 0.160 0.061 0.009

Gender -0.160 0.066 0.015

PMT constructs

Perceived vulnerability 0.098 0.024 0.000

Response efficacy 0.477 0.019 0.000

Self efficacy 0.741 0.023 0.000

Rabies protective behaviors

PMT constructs 0.298 0.053 0.000

School No. 4 -0.228 0.058 0.000

SE, standard error; PMT, protection motivation theory.

Figure 1. Path diagram of the structural equation model. PMT, protection motivation theory.

Media Gender

YouTube

0.160 -0.160

PV3

S4

-0.228

0.532

0.827

0.795

0.548

PB1

PB2

PB3

PB4

1.000

0.701

0.813

0.704

0.657

0.839

0.741

0.036

Perceived vulnerability (PV)

Response efficacy (RE) PMT construct Rabies protective behaviors (PB)

School No.4

Self-efficacy (SE)

0.098

0.477 1.404 0.298 0.160

RE2

RE4

SE2

SE3

SE6

Boy

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Rabies Protective Behaviors of Students

DISCUSSION

This study used PLS-SEM to predict structural relationships in our model based on PMT and to determine the key factors related to RPB among primary school students. PMT consists of a combination of 4 constructs (PS, PV, RE, and SE). The stu- dents were found to have good levels of PV, RE, and SE (43.9, 68.6, and 73.2%, respectively). The students’ overall scores were only fair for PS, at 54.5%. This finding is consistent with the results of a study by Kumsri [34] but inconsistent with 2 other previous studies [14,35]. The reason why most fourth- grade students achieved only a moderate level for PS may have been that PS, more than the other constructs, is age-depen- dent [15], and children and adults are at different stages of cognitive development [23].

According to the results of the path analysis, the PMT con- structs (β, 0.298; SE, 0.053; p<0.001) and the S4 school indica- tor (β, -0.228; SE, 0.058; p<0.001) had significant relationships with RPB. The students in S4 had the lowest rate of RPB of the participants. Accordingly, S4 was located in an area with fewer reported rabies outbreaks than in the other areas where schools were located, and teachers and parents may not have been fo- cused on rabies prevention [36].

The study findings also showed that, of the PMT constructs, SE was the strongest predictor (β, 0.741; SE, 0.023; p<0.001), which is consistent with the findings of previous studies [15,

18,19,23]. This positive correlation indicates that individuals with a high SE score can consistently act against rabies, reduce their own risk of rabies, protect their health, and prevent the negative consequences of poor RPB. Therefore, when design- ing educational interventions, it is essential to emphasize SE to mitigate the threat of rabies [18]. PS, however, was not a significant predictor of PMT constructs and RPB in this study, which is a similar finding to those of some previous studies [14,17,20,22,37] and an inconsistent finding with others [11,15, 16,34]. The PS scores of the participants in this study were not high. The mean value was 8.59±1.57, and most students were unsure as to the severity of rabies. Nevertheless, PS can be de- cisive as it relates to PMT constructs since, if students are aware of the consequences and harms of rabies, protection motiva- tion will in turn increase [18]. Therefore, when designing edu- cational programs, it is essential to pay special attention to PS by incorporating anecdotes from children who experienced dog attacks [38].

Notably, media platform preferences and gender were found to be significantly associated with PV. According to the find- ings of a study by Rogers and Prentice-Dunn [39], a higher quan- tity of information can increase respondents’ PV scores, and Chambers et al. [21] found that low vulnerability may be tied to a lack of knowledge about rabies risks factors and the in- ability to recognize one’s personal risk of rabies. Since YouTube is a popular media platform among students, it can be used to

Figure 2. Importance performance map analysis. PV, perceived vulnerability; RE, response efficacy; SE, self-efficacy.

100

90

80

70

60

50

40

30

20

10

0 0.020 0.040 0.060 0.080 0.100 0.120 0.140 0.160 0.180 0.200 0.220

Total effect

Ra bi

es p

ro te

ct iv

e be

ha vi

or s

Importance-performance map PV3 RE2 RE4 SE2 SE3 SE6 S4 Boy Youtube

Quadrant B

Quadrant C

Quadrant A

Quadrant D

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disseminate targeted informative videos according to their lev- el of risk. Another study also found that females had a higher degree of PV than males regarding health beliefs and health behaviors [19].

Although this study found that only 3 PMT constructs were associated with RPB, it still cannot be concluded that the non- statistically significant constructs had no influence. In addition, our model explained only 1 aspect of the total variance of the outcome variable. This indicates that several influential factors were not included and suggests that further research must be conducted.

Another noteworthy finding of this study was its examina- tion of the importance and performance of factors associated with RPB. Our findings suggest that the RE4 (‘I think not inter- vening with animals when they are fighting will help to prevent rabies infection’) and S4 indicators in quadrant D, which had low performance but high importance, urgently require im- provement. As such, the RE4 indicator can be considered a key factor related to RPB. Most students, however, were not aware that avoiding fighting animals is an effective rabies prevention behavior. S4, which was also in quadrant D, had a substantial total effect on RPB and a very low performance score. Therefore, S4 and schools in the surrounding area should be the first place where interventions to promote RPB are conducted.

The 3 indicators in quadrant A (RE2: ‘I think that informing parents or people about the annual rabies animal vaccination will help to prevent rabies infection,’ SE2: ‘I am confident that I can reduce my risk of contracting rabies by informing local in- dividuals to vaccinate their pets,’ and SE6: ‘I am confident that if I do not intervene with fighting dogs, I can reduce my risk of contracting rabies’), which had both high performance and importance, indicate that students already realized that those indicators assisted in rabies prevention. However, because those indicators had very high total effects on the dependent variable, they should still be reinforced in future education programs, particularly RE2 and SE2, in order to encourage stu- dents to talk to family and community members about vacci- nating their pets against rabies on an annual basis, which they already understood to be effective.

The 2 indicators in quadrant B (PV3: ‘If after being bitten you wash the wound with clean water and soap several times for at least 15 minutes, you will have a greater chance of not con- tracting a rabies infection,’ and SE3: ‘I am confident that if I im- mediately inform my teachers/parents after being bitten, scrat- ched, or licked by a mammal, I can reduce my risk of contract-

ing rabies’), which had high performance but low importance, indicate that those indicators were not important for RPB. Stu- dents’ scores for those indicators were still good, however, es- pecially for SE3, which had the highest performance score out of all of the indicators. This indicator ultimately has little influ- ence on RPB. Nevertheless, it is still important to promote edu- cation related to these indicators to students in addition to pro- moting education related to the RE4, RE2, SE2, and SE6 indica- tors. Boy and YouTube indicators were in quadrant C and had both low performance and importance. Even though those indi- cators can be considered low-priority for improving RPB, it may still be useful to use YouTube as a tool for the dissemination of rabies education in future prevention and control programs.

This study has some limitations. First, the data for this study were collected using a cross-sectional survey. Therefore, the relationship that was observed between the PMT sub-constructs and other variables needs to be verified in future longitudinal studies. Second, since the participants in this study were fourth- grade students, some PMT constructs, such as perceived re- wards and perceived response cost, were not investigated. In future studies of families, these constructs should be added since perceived rewards are known to influence threat apprais- al and perceived response cost is known to influence coping appraisal [39].

The results of this study indicate that PMT is a useful frame- work for predicting behaviors, especially concerning individu- als’ intentions and motivation related to RPB. Future studies about RPB among school students that are based on PMT should focus on increasing RE, especially for the RE4 indicator and RE2 indicators. In addition, the improvement of SE should also be emphasized so that students feel encouraged to inform family and townspeople of the benefits of annual vaccination against rabies for their pets (SE2) and avoid animals that are fighting (SE6). The results of the present study showed a highly signifi- cant relationship between PMT and RPB. If students have more confidence to act, they would be more likely to adopt rabies prevention tactics in high-risk situations [40]. The PMT concepts that were shown to be most influential can be used when de- signing tools and implementing and evaluating educational interventions to prevent rabies among children.

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

439

Rabies Protective Behaviors of Students

FUNDING

This project was supported by the Faculty of Public Health at Burapha University.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the students, fami- lies, and teachers for their cooperation. Our great appreciation is also extended to Associate Professor Wathna Soonthorndhai and Lecturer John Daly (USA) for their time, supervision, useful discussion, critical reading, and editing of the manuscript.

AUTHOR CONTRIBUTIONS

Conceptualization: ML, NM, AW, PA. Data curation: ML. For- mal analysis: ML. Funding acquisition: ML, NM, AW, PA. Meth- odology: ML, NM, AW, PA. Project administration: ML. Visual- ization: ML. Writing – original draft: ML. Writing – review & ed- iting: ML, NM, AW, PA.

ORCID

Mayurin Laorujisawat https://orcid.org/0000-0003-0119-5770 Nipa Maharachpong https://orcid.org/0000-0003-2838-1805

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