*Perceived Benefits Matter the Most*

One of our central findings is that among all constructs of the HBM, Pakistani people in Depalpur are moved by the perceived benefits of COVID-19 prevention to comply with prevention guidelines issued by the WHO and the Ministry of Health in Pakistan. When compared to recent studies, the cues to action for the study participants could have been influenced by misinformation regarding the causes and treatment of the SARS-CoV-2 virus, distrust in local government and media figures, misplaced assurance in the effectiveness of nonmedical treatments, and conspiracy narratives related to religious beliefs concerning a viral disease like COVID-19 [19,38]. A recent study in Macao, China, found that perceived susceptibility was the motivation for the participants to comply with prevention guidelines [39].

The other constructs of the HBM, such as perceived susceptibility to getting infected, perceived severity of COVID-19 disease, perceived barriers of preventative action, or cues to action did not seem to alter people's prevention behaviors. The lack of response to threats and vulnerability may be attributable to a general culture of external locus of control (i.e., that what happens is often out of people's control) since external threats are numerous and often unavoidable. The general public attitude amounts to "how worse can it get anyway", given the chronic economic and socio-cultural challenges such as high unemployment and underemployment and extreme social and health inequities.

Perceived benefits in the HBM model refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to decrease the risk of disease (in this case, COVID-19). The perceived barriers refer to an individual's feelings concerning the obstacles that may impede their behavior change, which means that when an individual believes a particular action will increase COVID-19 susceptibility or its seriousness, they are thus less likely to engage in preventive behavior [38,39]. Given our findings of primary drivers of behavior change, it is expected that among people of Pakistan, the perceived benefits of any COVID-19 interventions will outweigh the perceived barriers [40,41]. In this study, the perceived barriers were mainly regarding the ability to adhere to recommended social distancing and self-isolation.

In summary, while a range of health behaviors can be explained using HBM, with the exception of benefits, other constructs of HBM did not explain the study participants' health behaviors in Pakistan. In general, when considering individual behavioral change, poor knowledge and risk perceptions of the disease, illness, or situation are usually considered the main barriers to the change. While the ways in which people perceive risk does not necessarily correlate with the actual risk, their risk perception has been shown to influence their decisions to engage in individual protective behaviors [41]. According to the HBM, an increase in perceived threat (a combination of perceived severity and perceived susceptibility) to a particular health problem would increase engagement in behaviors to reduce their risk of developing the health problem [42,43]. Thus, HBM predicts that individuals who believe they are at low risk of developing an illness are more likely to engage in unhealthy, or risky, behaviors, and those that perceive a higher threat have a higher likelihood of engagement in health-promoting behaviors. In this study, the researchers found that a majority of the study participants believed that there was no cure for COVID-19 (79.4%) and doubted the Pakistani government's ability to provide proper care for those affected by the virus (68.8%). These beliefs would imply a high perceived severity of the disease and, when combined with high perceived susceptibility, would result in an overall high perceived threat of the virus among the participants.

While the cues to actions were low, the majority of the survey participants was practicing several of the protective measures such as avoiding visiting any crowded place or any social gathering, non-essential travel, and using public transportation. However, many of

the participants were not following the basic protective measures (e.g., hand washing, use of face-covering in public, social distancing) when they left their homes. The lack of performing these behaviors could have been due to a number of issues such as the inability to afford soap, hand sanitizer, and/or gloves, as well as a low health literacy. The practicing of protective behaviors was the highest among those between the ages 20–34 years, females, those with at least a high school education, those in homes with less than five people, and single or separated/divorced individuals.

This study's findings should be interpreted in the context of its several limitations. First, the study is quantitative and cross-sectional. Therefore, many questions could not be answered such as why perceived benefits and not the other constructs of HBM significantly shaped our study participants' prevention behaviors. Secondly, the self-reported data may have suffered some social desirability bias, particularly because the surveys were conducted in a face-to-face setting. Third, the sample size (*n* = 500) and the study setting may pose limitations on the generalizability of the findings to other parts of the country. Also, we did not conduct the power test to determine the size of the sample, but instead relied on a reasonable sample size estimate. Fourth, the mapping to the HBM model was done after the data collection. It would have been better to do such mapping prior to data collection. Finally, the survey was conducted only three to four months into the COVID-19 pandemic, and some ground realities may have changed later on during the pandemic. Regardless of these limitations, this is an exploratory study that could help the Pakistan government understand the knowledge, attitudes, and practices of the general public concerning COVID-19. Also, the study findings have important implications for COVID-19 vaccine acceptance.
