Introduction

The outbreak of the novel coronavirus disease (COVID-19) is now considered pandemic with total number of confirmed cases exceeded 247 million cases by the end of October 2021, and number of deaths reaching approximately 5 million (World Health Organization [WHO], 2021). COVID-19 caused negative consequences globally on individuals, communities and governments (WHO, 2020). For example, the lockdown and curfew used by most countries to slow down the spread of this virus has negative financial consequences, since most shops and factories were forced to close. Also, the psychological impact of this pandemic was strong and included severe levels of anxiety, depression, and phobia (WHO, 2020).

Jordan is a middle eastern country with a population of approximately 10.5 million (Department of Statistics, 2020). The number of COVID-19 cases in Jordan reached to approximately 862,000 cases by the end of October 2021, while the total number of deaths was 11,000 (WHO, 2021). Early and strict governmental orders were applied during the mid of March 2020 which included lockdown and complete curfew, followed by fines and risk of being imprisoned for any Jordanian who break these orders (The Jordan Times, 2020). As Jordan was approaching the end of March, the order of curfew was modified, allowing people to go out for shopping for necessary groceries between 10AM until 6PM. Afterwards, restrictions were removed gradually, and people were allowed to stay outside until 11PM. Meanwhile, preventive measures were highly recommended such as masks and social distancing (The Jordan Times, 2020). During the period December 2020 – January 2021, several COVID-19 vaccines have been approved, and were being distributed and administered globally to control the pandemic (WHO, 2021). Afterwards, Jordanians were being encouraged by the government and health officials to take the vaccine, and by the end of June 2021, the curfew order was canceled (Ministry of Health [MOH], 2021). As of November 2021, more than 3,680,000 Jordanians took the two doses of COVID-19 Vaccine (MOH, 2021).

COVID-19 is highly transmissible and contagious (Centers for Disease Control and Prevention [CDC], 2020). So, it is important to determine individuals’ intentions towards COVID-19 seeking help, because this may help healthcare professionals to act and intervene on cases at earlier stages. Help-seeking behaviors in the context of COVID-19 and in this study focuses mainly on COVID-19 PCR testing, contacting the primary care provider, and accessing health clinics or emergency departments for having symptoms similar to COVID-19 (Ravert et al., 2021; Shahrour et al., 2021). Seeking help for COVID-19 (e.g. PCR testing) as soon as the symptoms appear helps healthcare professionals to trace those who were with close contact with an infected person, and screen them and apply preventive measures for them such as quarantine and masks if their test results were negative, or start isolation and treatment if they were found to have positive results. Consequently, seeking help for COVID-19 at earlier stage of developing signs and symptoms helps in slowing the spread of this pandemic. To that effect, however, it is important to determine the factors that may affect the intention to seek help for COVID-19. Identifying these factors may provide healthcare leaders with recommendations and suggestions on how to encourage people to seek help and how to control barriers. Examples of the barriers identified in the literature included negative attitudes toward COVID-19 preventive measures and testing, discrimination or stigma if diagnosed with COVID-19, and poor knowledge regarding COVID-19 (Das et al., 2021; Noorrizki et al., 2021; Shahrour et al., 2021).

The Theory of Planned Behavior (TPB) was used to guide this study and examine participants’ intention towards seeking help for COVID-19. According to this theory, the actual behavior is highly affected by a person’s intention to perform that behavior (Fishbein & Ajzen, 2010). This theory assumes that individuals’ intentions to perform a certain behavior are influenced by: a) their attitude toward that behavior, b) subjective norm which means the social approval or disapproval of performing that behavior, and c) perceived behavioral control which means the perceived barriers and the amount of control individuals have over their decision (Fishbein & Ajzen, 2010). The TPB is one of the most commonly used theories in predicting behaviors, and it successfully predicted a wide variety of healthy behaviors in previous studies (Aldalaykeh et al., 2019; Fishbein & Ajzen, 2010; Mak & Davis, 2014; Mo & Mak, 2009; Woods, 2013). In the context of COVID-19, several studies used the TPB to predict successfully intentions and actual behaviors related to social distancing, PCR testing, and compliance with health protocols (Das et al., 2021; Gibson et al., 2021; Noorrizki et al., 2021). This theory was chosen to guide this study because it consistently showed high predictive power (i.e., explained variance), and it includes cognitive as well as social factors to predict intentions and behaviors (Aldalaykeh et al., 2019; Fishbein & Ajzen, 2010; Mak & Davis, 2014; Woods, 2013).

Previous studies showed the importance of health-related knowledge in improving help seeking behaviors (Adela et al., 2020; Al Ali et al. 2017; Batterham et al., 2013; Chan et al., 2014; Paul et al., 2020; Prasetyo et al., 2020). People who have a higher level of knowledge about a certain disease or health issue are more likely to seek help than others (Adela et al., 2020; Chan et al., 2014; Khan et al., 2020; Paul et al., 2020; Prasetyo et al., 2020). In the context of COVID-19 several studies indicated the importance of COVID-19 knowledge in improving help-seeking behaviors such as PCR testing or contacting the primary care provider and applying preventive measures such as masks, social distancing, and hand washing (Bonner et al., 2020; Boot et al., 2021; Hussein et al., 2021; McCaffery et al., 2020; Noorrizki et al., 2021; Shahrour et al., 2021) So, it is important to examine the effect of COVID-19 knowledge level on individuals’ intentions to seek help for COVID-19. Our hypothesis would be participants’ attitude toward COVID-19 seeking help, subjective norm, perceived behavioral control, and COVID-19 knowledge levels significantly explain participants’ intention toward COVID-19 seeking help. The purpose of this study is to identify participants’ intention toward COVID-19 seeking help and the factors affecting their decision.

Methods

A cross sectional correlational design was used in this study. An online survey using Google Forms was used for data collection. The sample included Jordanians who were 18 years or older, residing in Jordan during COVID-19 outbreak. Those who were already treated for or diagnosed with COVID-19 were excluded. The online survey was posted on social media websites and applications, mainly Facebook and WhatsApp. Snowball sampling technique was used to ensure continuous, quick, and wide spread of the survey. The use of convenience sampling method in this study was more appropriate because of the difficulty to have a well-defined population, and thus create a very long list for potential participants that enable random sampling method. In other words, convenience sampling method was more feasible, especially considering restrictions during the pandemic such as curfew. Data collection started on April 11, 2020 and completed on April 20, 2020. The sample included 780 Jordanians. The sample size was calculated using G*Power software, which takes into consideration effect size, power, precision level, and number of predictors (Faul, Erdfelder, Buchner, & Lang, 2009).

Institutional Review Board (IRB) approval was obtained from Jordan University of Science and Technology. Potential participants were informed in the online survey that their participation is voluntary and no identifying information will be obtained, and information will be confidential and no access to information except for the research team. Also, they were informed that the survey is very short, and it will take no longer than 5–10 minutes.

Results

Figure 1 shows the frequency of correct signs/symptoms of COVID-19 as reported by the participants. Participants showed high knowledge level regarding COVID-19 signs/symptoms, as the most common and true symptoms were endorsed by the majority of participants. Fever, dry cough, and shortness of breath (dyspnea) were endorsed by 95.1%, 88.8%, and 91.7% of participants respectively (Figure 1). Also, the participants were able to differentiate that sneezing, itchy skin, red eyes, and vomiting are not related to COVID-19. For example, only 5% and 16.4% of participants reported itchy skin and red eyes respectively as correct signs/symptoms of COVID-19 (Figure 1). The mean total score of COVID19 Knowledge was 85.47%±14.20, and it ranged between 42.86%-100% (Table 2). Approximately, 73% of the sample have a total knowledge score equal to or higher than 85%.

Participants had high positive attitude towards seeking help for COVID-19 (Table 2). Also, they reported a high social approval (SN) from family and significant others toward seeking help. In addition, they reported a high ability (PBC) to seek help if they develop the typical signs and symptoms, and high intentions towards COVID-19 help-seeking.

Discussion

This study used the concepts of the TPB along with COVID-19 knowledge level to explain intentions to seek help. The results indicated that participants had high and strong intentions towards seeking help for COVID-19 including PCR testing, contacting the primary care provider, and accessing healthcare clinics or emergency departments. This is consistent with the findings of several other studies in other countries (Campbell et al, 2021; Ravert et al., 2021; Shahrour et al., 2021). This could be related to several reasons. First, the findings indicated that participants had very high positive attitude towards help-seeking. Second, they showed high social approval from family and significant others towards help-seeking. The Jordanian culture is collectivist in nature, and this may have increased the effect of subjective norm on intentions (Aldalaykeh et al., 2019; Al Ali et al., 2017). Third, participants showed a high control over their decision to screen themselves and they also reported lower barriers toward seeking help. This could be related to lower cost of treatment, as 72% of Jordanians have health insurance (DOS, 2020; MOH, 2021). For example, the PCR is test is free for suspected cases and the cost of healthcare services is affordable even if the person does not have health insurance (DOS, 2020; MOH, 2021). Fourth, the government and non-profit organizations conducted several campaigns through local TV channels and social media that explained all details about COVID-19 such as signs/symptoms, methods of transmission, prevention methods, and treatment approaches (The Jordan Times, 2020). These campaigns could improve the knowledge level about this pandemic, and this was supported by the high knowledge level the participants had about COVID-19 signs and symptoms.

The results of this study showed a significant and positive association between COVID-19 knowledge and the intention to seek help. This is consistent with previous studies that showed a positive association between high knowledge levels and help-seeking intentions or behaviors (Adela et al., 2020; Al Ali et al. 2017; Batterham et al., 2013; Chan et al., 2014; Paul et al., 2020; Prasetyo et al., 2020). In the context of COVID-19, researchers found that the intentions or actual behaviors of PCR testing, social distancing, and complying with COVID-19 health protocols are highly affected by the level of COVID-19 knowledge, whereas poor COVID-19 knowledge is considered a barrier in adopting these healthy and preventive measures (Bonner et al., 2020; Boot et al., 2021; Hussein et al., 2021; McCaffery et al., 2020; Noorrizki et al., 2021; Shahrour et al., 2021).

The findings of the study showed that participants have a high knowledge level about COVID-19. This is consistent with previous studies that showed a high knowledge level regarding COVID-19 in many countries including Egypt, Indonesia, USA, Cameron, Pakistan, Philippines, and some European countries (Adela et al., 2020; Boot et al., 2021; Campbell et al., 2021; Hussein et al., 2021; Khan et al., 2020; Prasetyo et al., 2020; Sari et al., 2021). The high knowledge levels in this sample could be explained by sample characteristics since the majority were relatively young and having a bachelor’s degree. This may facilitate understanding of the information related to COVID-19 and the easy access to this information through the use of social media. Also, the timing of the data collection (mid of April 2020) allowed participants to listen and watch awareness raising campaigns about COVID-19 regularly since the beginning of the pandemic, which may have enhanced their retention of information and improved their knowledge levels. Finally, high knowledge level could be related to the unidimensional measurement approach used to estimate knowledge level. In this study, we measured knowledge level by examining only COVID-19 signs and symptoms. If we measured other dimensions such as preventive measures (masks, hygiene, social distancing, etc.), treatment approaches, or complications, knowledge levels may have been more variable.

The findings of this study supported the effectiveness of the theory of planned behavior in explaining intentions to perform healthy behaviors, as evidenced by the large explained variance of the dependent variable. This is consistent with previous studies that showed significant results of this theory in explaining intentions and wide variety of behaviors (Aldalaykeh et al., 2019; Fishbein & Ajzen, 2010; Mak & Davis, 2014; Mo & Mak, 2009; Şimekoğlu & Lajunen, 2008; Thornton & Calam, 2010; Woods, 2013). In the context of COVID-19, our results were consistent with other studies that used the TPB to successfully explain intentions toward PCR testing, social distancing, and complying with COVID-19 health protocols (Das et al., 2021; Gibson et al., 2021; Noorrizki et al., 2021). Another strength of the TPB is that its original variables showed high explained variance in the first step of regression model, and although the extension of the model by adding COVID-19 knowledge improved the explained variance, but it was modest. The TPB may help healthcare leaders and policymakers to focus their efforts on improving attitudes (e.g. through awareness campaigns) and decreasing the barriers to healthy behaviors or preventive measures during this pandemic or any future pandemics to ensure higher intentions and ultimately higher achievement of the actual behaviors (i.e. decrease the gap between intentions and behaviors).

Limitations of this study include the use of a convenience sampling method and online survey, and thus, the generalizability of the findings is limited only to those who have similar characteristics. Another limitation is the use of a cross-sectional design, which does not support causality. However, one of the strengths of this study is that all tested hypotheses are based on a well-established theory, which may help establish some bases of causality, especially with the use of multiple regression. One of the limitations is the use of unidimensional tool to assess COVID-19 knowledge level. However, no readily available tool was found during the time of the study. Another limitation is measuring intentions rather than the actual seeking behavior, although Ajzen clarified that that there is a strong positive correlation between intentions and actual behavior, many studies showed that there is a gap between the two concepts (Fishbein & Ajzen, 2010). Future studies should consider the use of longitudinal designs, random sampling, and a multi-dimensional tool to assess the COVID-19 knowledge level, and measure the actual behavior.

Conclusion

Participants showed a high level of knowledge regarding the COVID-19 signs and symptoms. This may positively affect their attitudes toward seeking help, leading to high intentions toward COVID-19 help-seeking. Also, high intentions were related to the strong social approval toward seeking help, and high perceived ability and control over the decision to seek help. To decrease the gap between intentions and actual behavior, regular awareness raising campaigns during early stages of the pandemic should be performed to improve knowledge level about the pandemic which may improve prevention measures, and promote help seeking behaviors. Consequently, this may facilitate early detection of cases, and slow the spread of COVID-19.