*4.2. Mediation Effect Testing*

The PROCESS macro was used to examine the multiple mediating roles of risk perception and PAR adoption in the relationship between government response and infection rate. We included the participants' gender, age, household registration, years of schooling, health status, urbanisation rate, and region as covariates. Table 4 shows that government response was positively associated with risk perception (b = 7.452, *p* < 0.001), whereas risk perception was negatively related to infection rate (b = −0.028, *p* < 0.01). Government response was positively associated with PAR adoption (b = 0.255, *p* < 0.001) and negatively related to infection rate (b = −0.859, *p* < 0.01). Risk perception showed a positive association with PAR adoption (b = 0.030, *p* < 0.001) and government response was negatively related to infection rate (b = −1.688, *p* < 0.05).

**Table 4.** Effects of government response on risk perception, PAR adoption, and infection rate.



**Table 4.** *Cont.*

Note: (1) Standard errors appear in parentheses; (2) \* *p* < 0.05, \*\* *p* < 0.01, \*\*\* *p* < 0.001.

The results of the bootstrap analysis are shown in Table 5. None of the 95% confidence intervals for the path coefficients included zero, suggesting that the total effects, direct effects, and indirect effects were all significant (−2.308, −1.688, and −0.62, respectively). The mediating effects accounted for 26.87% of the total effects. Specifically, the effect of the path 'government response → risk perception → infection rate' was −0.209, accounting for 9.06% of the total effects; the effect of the path 'government response → PAR adoption → infection rate' was −0.219, accounting for 9.49% of the total effects; and the effect of the path 'government response → risk perception → PAR adoption → infection rate' was −0.192, accounting for 8.32% of the total effects. Thus, risk perception and PAR adoption mediated the relationship between government response and infection rate not only in parallel but also sequentially.


**Table 5.** Bootstrap analysis of multiple mediation effects.

Note: (1) N = 7092; (2) Covariates: gender, age, household registration, years of schooling, health status, urbanisation rate, and region; (3) X = government response, M1 = risk perception, M2 = PAR adoption, Y = infection rate; (4) bootstrap sample size = 1000.

#### **5. Discussion**

Based on data from a nationwide survey conducted by a research group in mainland China in February 2020 and data on infection cases in selected cities in the 1.5 years following the outbreak of COVID-19 in December 2019, this study investigated the sustained effect of an early government response to the pandemic (i.e., the relationship between an early government response and the COVID-19 infection rate after 1.5 years). The contributions of the study are as follows. It offers novel insights into the effects of the government's implementation of a single policy and the multiple effects of prevention measures by comprehensively sorting out various government responses and evaluating the persistent effects of early intervention policies on the COVID-19 infection rate. In addition, this study reveals multiple mediating effects of an early government response on the COVID-19 infection rate. It confirms the role of social intervention in preventing the spread of epidemics, from a perspective that differs substantially from those of environmental science [55] and epidemiology [56].

First, this study carefully combed through the various epidemic prevention initiatives in the surveyed cities to construct a composite indicator to measure early intervention by the Chinese government and found that the government's early response was significantly negatively associated with infection rate. By collating the COVID-19 prevention and control announcements released on the Chinese government's official website, we summarised the initiatives implemented in the early stages of the COVID-19 outbreak, including 20 different intervention strategies, which can be classified into six categories that each point to a different issue in the outbreak prevention and control process. The rigorous government interventions implemented in the early stages and the rapid and active implementation of these measures are what prevented China, a country with a large population and one of the earliest COVID-19 outbreaks, from developing more COVID-19 infections and deaths than other countries [3]. This suggests that China's aggressive and multifaceted response may have prevented a worst-case scenario, inhibited the global spread of COVID-19, and mitigated the global impact of the virus [4]. Thus, the Chinese government's early COVID-19 interventions and their effects deserve to be noted.

This study's findings have important implications for future efforts to contain the spread of the epidemic. It reveals that the government's response to COVID-19 and other pandemics should not be reactive but proactive, and should not involve a single initiative but a complete set of action strategies. The six categories of measures provide a more detailed picture of the Chinese government's response to a pandemic and can serve as a set of action strategies to prevent the spread of COVID-19. This empirical study also shows that government response should be more comprehensive, scientific, and equitable, including disease detection, and combined with that, Professor Jing Jun advocated to build an epidemic preparedness and response system including incident verification, isolation of the source of infection, public communication, travel warnings, prevention of systemic breakdown, protection of human rights, the right to health of the whole community and control of social fears" [57]. Some studies have also found that a government's response explains differences in prevention and control effectiveness across countries [3], and the findings in this paper provide theoretical and practical insights into the response to epidemics in countries with the same social context.

Subsequently, this study determined that China's early government response had a sustained impact on the COVID-19 infection rate. Although previous studies are consistent with the findings of Post et al. that the point of change in the daily effective contact rate overlapped with the moment of government response [14], Lai et al. found that if the government's response had been implemented earlier, the number of COVID-19 cases could have been reduced [4]. Other scholars have analysed the impact of strict quarantine measures versus reopening public places on the early spread of COVID-19 [58], including COVID-19 infection and mortality rates [17,19,58–62]. Although many studies have shown that both early and severe prevention and control policies, as well as later, lenient intervention strategies, inhibited the spread of COVID-19, they have neglected the possibility that an early government response may also have had a sustained effect on the COVID-19 infection rate in later stages. Meanwhile these studies, in highlighting the impact of an early government response on the infection rate of the epidemic, have emphasised that the lag in response may lead to a delayed reduction in the infection rate. In contrast, this paper emphasises the sustained reduction in the infection rate that occurs as a result of the sustained effect of the government response. The present study established a negative association between an early government response and COVID-19 infection rates over the past year and a half, suggesting that early and severe interventions have a lasting effect on the spread of the epidemic.

This study also delved into the mechanisms underlying the impact of an early government response on the prevalence of an epidemic (i.e., why does an early government response have a sustained impact on the COVID-19 infection rate?) Two mechanisms of action were identified. The first is that an early government response affects the COVID-19 infection rate vis-à-vis its influence on people's risk perception. Numerous studies have

proven the role of scientific, transparent information in risk perception during an epidemic, including 'the information release' and 'publicity and education' measures, which enable people to form an objective assessment of the outbreak and foster an appropriate risk perception. Government information on public emergencies indirectly influences protective behaviour through individual factors such as risk perception, because of detailed outbreak information and positive risk communication. Statistical information on the outbreak and detailed information on the trajectory of confirmed cases make individuals aware of the seriousness of the pandemic, and detailed information enhances individual risk assessment [38]. At the same time, this poses a challenge for governments attempting to reduce the impact of fake news in the information age and in social media. In terms of the response process, both the relevant Supreme Court directive and the 'Rumours exposed website' created by Tencent (the parent company of WeChat) helped reduce the spread of confusion and panic [63]. The impact of government response on public perception of risk is therefore not achieved by a single measure but rather by a combination of them. When faced with a rapidly spreading pandemic such as COVID-19, a drastic and strict government response effectively increase people's perception of the risk of infection, resulting in more cooperative behaviour that inhibits the spread of the virus and reduces its infection rate. Studies have pointed out that increasing people's risk perception contributes to superior suppression of virus transmission.

The second mechanism is that an early government response affects the COVID-19 infection rate by increasing the public's adoption of PARs. Scholars have found that an early government response, such as swiftly disseminating COVID-19 knowledge, monitoring infected cases, and restricting population movement and interpersonal contact, including lockdowns, travel restrictions, and shutting down public places, have a direct contribution to public's adoption of PARs. Therefore, government response in the early stages of COVID-19 outbreak will control the spread of disease by influencing individuals' protective behaviours. While risk perception and the public's adoption of PARs have also been the focus of previous studies, this study identified risk perception as an important mediating factor between government response and the public's adoption of PARs. People's compliance with recommended protective behaviours is not the ultimate goal of government response to COVID-19, reducing infection and mortality rates is the real goal. Studies have rarely explored the relationship between the public's adoption of PARs and infection rates. This paper extends the evaluation of the effectiveness of government response in reducing the COVID-19 infection rate by analysing the relationship between early government response, risk perception, the public's adoption of PARs, and COVID-19 infection rate.

In addition, this study found a correlation between risk perception and the public's adoption of PARs, and showed that the effect of an early government response on the COVID-19 infection rate may exert multiple mediating effects through risk perception and the public's adoption of PARs. That is, an early government response may influence people's risk perception, which in turn promotes their adherence to recommended protective behaviours and ultimately suppresses the COVID-19 infection rate. In the past year, repeated outbreaks of COVID-19 in Xinjiang, Beijing, Guangzhou, Nanjing, Xiamen, and other provinces in China have been quickly contained rather than spreading to multiple provinces across the country, as was the case with the initial Wuhan outbreak. A major reason for this success is that the Chinese population developed an adequate level of risk perception after the Wuhan outbreak, and when confronted with subsequent COVID-19 outbreaks, they were able to quickly adopt recommended protective behaviours to protect themselves and contain the spread. These are strong indications that an early government response has a sustained and important impact on later prevention and control. This shows how government response and infection rate at the macro level are connected to individuals at the micro level. These findings not only enrich the literature but also provide important practical insights.

In practice, it would be undesirable to relax outbreak control, because we are still in the midst of the pandemic and far from being completely victorious over COVID-19. However, persisting with strict prevention and control in countries where the outbreak is under better control is not advisable; this study reveals that instead, increasing risk perception and promoting the public's adoption of PARs are feasible practical strategies. People's risk perceptions should be continuously cultivated. In the post-pandemic era, it will be important to continue providing the public with scientific information on COVID-19 and how to protect themselves and others. This will foster the formation of health beliefs that will enable COVID-19 to be defeated with ease and increase cooperation between the public and the government. This will not only effectively reduce the administrative costs of epidemic invention for the government but also encourage the public to respond to COVID-19 variants with flexibility. Adopting PARs can enable individuals to protect themselves and interrupt the chain of epidemic transmission. Studies in the field of infectious diseases have demonstrated that individual health behaviours play a direct role in overcoming diseases. Why was the Chinese government able to effectively control the spread of the virus during the COVID-19 pandemic? The answer lies in the public's adoption of PARs such as physical distancing, mask-wearing, and handwashing. The multiple mediating roles of risk perception and PAR adoption remind us that in the postpandemic era, inducing people to adopt recommended protective behaviours can intervene in their risk perception, and vice versa. Once a reasonable level of risk perception has been developed, it can continuously guide people to adjust their health behaviours in response to a health crisis and eventually help to overcome the crisis.

Therefore, our findings prompt us to further consider that, first, government response to pandemics should not be reactive but proactive, and should consider the cultivation of public health behaviours and health beliefs. Second, the response should not be singular but systemic and comprehensive, and should consider the effectiveness of the interactions between the various measures. Third, it should not only emphasise 'just-in-time' and 'short-term' effects but should also focus on long-term and sustained effects. We suggest that in the face of an unknown pandemic, the emphasis should be on predictive awareness of the epidemic, the construction of 'an epidemic preparedness and response system', and the establishment of a multi-source early warning system for infectious diseases that incorporates the public, companies, research institutions, public participation in in-hospital reporting, and other data sources.

### **6. Limitations and Avenues for Future Research**

Although our study contributes to both the literature and anti-epidemic practice, several limitations should be noted. First, the data on both risk perception and the public's adoption of PARs were based on the results of a 2020 survey conducted at the outset of the COVID-19 outbreak, when people's understanding of the disease was much more limited than it is now. With a greater understanding of COVID-19, people's risk perceptions are likely to change and they are more likely to comply with recommended protective behaviours for self-protection. Second, risk perception and the public's adoption of PARs may be influenced by several factors aside from government response, such as the severity of COVID-19. There may be regional and group differences in risk perception and the public's PAR adoption depending on regional and group differences in the severity of COVID-19 [64]. Such regional differences should be considered in future research. Third, multiple mechanisms may underlie the sustained impact of an early government response on the rate of COVID-19 infection, only one of which is revealed in this paper. Future studies should explore other potential mechanisms underlying this impact.

In addition, when we look at the international situation, we see both the differences in the health care base and the historical characteristics of each country's health care system, leading to differences in each country's response capacity. Russia has a massive government sanitary epidemiology service (Rospotrebnadzor), which is unique in the world for historical reasons, which has effectively prevented the importation of the epidemic [65].

However, there was not enough time to respond before COVID-19 swept through Brazil. The epidemic hit the country's economy hard, with significant regional disparities in health care capacity and the spread of the virus to poorer areas with less capacity [66]. Due to its low government spending on health care and lack of health care infrastructure, India leapt to the forefront of the world's epidemic [67]. Therefore, it remains an open question whether our findings shed light on how other countries' government response affects the infection rate, and whether this pathway still exists.

#### **7. Conclusions**

This paper investigates the sustained effect of an early government response on the rate of COVID-19 infection based on national survey data and infection data on Chinese cities. The results indicate that the early response of China's government significantly reduced the country's COVID-19 infection rate and that this this impact worked through risk perception, through the public's adoption of PARs, and through risk perception and the public's PAR adoption in a chain-mediated manner. These findings have great practical value. In showing how government response and infection rate at the macro level are connected to the behaviour of individuals at the micro level, they provide viable directions for curbing the spread of infectious diseases like COVID-19.

**Author Contributions:** Conceptualisation, T.D. and G.S.; methodology, T.D.; software, T.D.; validation, Z.S. and G.S.; formal analysis, T.D.; investigation, G.S., Z.S. and T.D.; resources, T.D. and G.S.; data curation, T.D.; writing—original draft preparation, T.D.; writing—review and editing, G.S. and Z.S.; visualisation, G.S. and Z.S. and T.D.; supervision, G.S.; project administration, Z.S. and T.D.; funding acquisition, G.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This study was supported by grants titled *Social mentality and prevention and control in response to major public health emergencies* (B200203041 and B200207033) from Hohai University's Central University Basic Scientific Research Business Expenses Project Funding and Population Research Fund of Jiangsu Province JSPA9002.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of School of Public Administration of Hohai University (protocol code 2021006 and 8 October 2021).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data are not publicly available, following the decision of the ethics committee on how to conduct this study.

**Acknowledgments:** Thanks to Huicong Liu, Qi Yang, Lin Zhu, Junzhuo Xu, Xiaocheng Zhang, Likun Gu, and You He for their help in collecting data.

**Conflicts of Interest:** The authors declare no conflict of interest.
