International Journal of

Environmental Research
and Public Health

Article
Mediating Effects of Risk Perception on Association between
Social Support and Coping with COVID-19: An Online Survey
Dian-Jeng Li 1,2,3 , Nai-Ying Ko 4 , Yu-Ping Chang 5 , Cheng-Fang Yen 1,6, * and Yi-Lung Chen 7,8, *

1 Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University,

Kaohsiung City 80708, Taiwan; u108800004@kmu.edu.tw
2 Department of Nursing, Meiho University, Pingtung 91202, Taiwan
3 Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital,
Kaohsiung City 802211, Taiwan
4 Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City 70140, Taiwan;
nyko@mail.ncku.edu.tw
5 School of Nursing, The State University of New York, University at Buffalo, Buffalo, NY 14260, USA;
yc73@buffalo.edu
6 Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City 80708, Taiwan
7 Department of Healthcare Administration, Asia University, Taichung City 41354, Taiwan
8 Department of Psychology, Asia University, Taichung City 41354, Taiwan
* Correspondence: chfaye@cc.kmu.edu.tw (C.-F.Y.); elong@asia.edu.tw (Y.-L.C.);
Tel.: +886-7-312-1101 (ext. 6822) (C.-F.Y.); +886-4-2332-3456 (ext. 20106) (Y.-L.C.);
Fax: +886-7-313-4761 (C.-F.Y.); +886-4-2332-1206 (Y.-L.C.)



Abstract: Coronavirus disease 2019 (COVID-19) is a novel infectious disease which has had a great


impact on the public. Further investigations are, therefore, needed to investigate how the public
Citation: Li, D.-J.; Ko, N.-Y.; Chang, copes with COVID-19. This study aimed to develop a model to estimate the mediating effects of risk
Y.-P.; Yen, C.-F.; Chen, Y.-L. Mediating perception and confidence on the association between perceived social support and active coping
Effects of Risk Perception on
with the COVID-19 pandemic among people in Taiwan. The data of 1970 participants recruited from
Association between Social Support
a Facebook advertisement were analyzed. Perceived social support, active coping with COVID-19,
and Coping with COVID-19: An
risk perception and confidence were evaluated using self-administered questionnaires. Structural
Online Survey. Int. J. Environ. Res.
equation modeling was used to verify the direct and indirect effects between variables. The mediation
Public Health 2021, 18, 1550.
https://doi.org/10.3390/
model demonstrated that lower perceived social support was significantly associated with a higher
ijerph18041550 level of active coping with COVID-19, and this was mediated by a higher level of risk perception. The
present study identified the importance of risk perception on the public’s coping strategies during
Academic Editors: Paolo Roma, the COVID-19 pandemic.
Merylin Monaro and Cristina Mazza
Received: 18 January 2021 Keywords: risk perception; confidence; social support; coping strategy; COVID-19; SARS-CoV-2
Accepted: 2 February 2021
Published: 6 February 2021

Publisher’s Note: MDPI stays neutral 1. Introduction

with regard to jurisdictional claims in 1.1. Golobal Scenario of COVID-19 and Coping Strategies for Infective Respiratory
published maps and institutional affil- Disease Pandemics
iations.
Coronavirus disease 2019 (COVID-19) is a novel infectious respiratory disease caused
by a novel coronavirus (SARS-CoV-2). It causes physical symptoms including severe
pneumonia, pulmonary edema and multiple organ failure [1]. It emerged at the end of
2019 and soon became a major public health burden worldwide [2]. On 11 March 2020, the
Copyright: © 2021 by the authors. WHO declared the COVID-19 outbreak a pandemic due to the rapid virus spread and high
Licensee MDPI, Basel, Switzerland. death toll over the world [3]. As of 29 January 2021, there were up to one hundred million
This article is an open access article confirmed cases and over two million deaths in over 200 countries [4].
distributed under the terms and
People may change their daily routines due to the adoption of protective behaviors
conditions of the Creative Commons
against COVID-19 and search for additional information on the disease. Understanding
Attribution (CC BY) license (https://
how the public cope with a pandemic can help health professionals better understand the
creativecommons.org/licenses/by/
impact it has on their daily lives, the adequacy of policy for infection control, and the future
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 1550. https://doi.org/10.3390/ijerph18041550 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 1550 2 of 12

outcomes of the pandemic. For instance, handwashing is the behavior most recommended
by the World Health Organization to protect individuals from contracting COVID-19 [5].
Several coping strategies during infectious disease pandemic were frequently used, such
as active coping (seeking social support), problem-focused coping (seeking alternatives,
problem-solving), and emotion-focused coping (avoidance) [6]. A longitudinal study re-
cruiting publics during COVID-19 also indicated that several coping strategies, specifically
seeking social support, engaging in distractions, and seeking professional help, were used
more frequently by those with more pandemic/lockdown distress [7].
In contrast with negative/passive coping, active coping is a stress-management strat-
egy in which a person directly works to control a stressor through targeted behavior [8].
It is generally considered adaptive, having been associated with fewer mood disturbances,
and enhanced self-efficacy [8]. Different types of coping strategies are associated with
diversities of psychological impacts. During the severe acute respiratory syndrome (SARS)
pandemic, active coping was positively related to perceived general health and life satis-
faction [9]. It was also reported to be associated with positively subjective wellbeing in
COVID-19 pandemic [10]. On the other hand, a web-based survey of people in China re-
ported that those with negative/passive coping strategies, such as do nothing or substance
abuse, had a higher level of psychological distress during the COVID-19 epidemic [11].
Moreover, individuals who have negative coping strategies for the COVID-19 pandemic
have a higher risk of being infected. For example, people with cognitive impairment and
mental illness are more vulnerable to COVID-19 infection as they have little awareness of
the risk and maladaptive coping strategies regarding personal protection [12]. Therefore,
investigations into factors that predict how the public actively cope with the COVID-19
pandemic are crucial to estimate the multi-dimensional impacts of COVID-19.

1.2. Influence of Perceived Social Support, Risk Perception, and Confidence with Active Coping
Whether perceived social support affects individuals’ coping strategies against the
threat of COVID-19 remains unclear. Chao reported that higher social support was pos-
itively associated with problem-focused coping among the elderly who experienced Ty-
phoon Morakot in Taiwan [13]. In addition, a study in the US revealed that support via
financial security was a predictor of adherence to the Centers for Disease Control and Pre-
vention (CDC) guidelines for infection control of COVID-19 [14]. However, how perceived
social support influences coping strategies against COVID-19 is not clear. Therefore, further
studies are needed to investigate whether there are factors that mediate the association
between perceived social support and active coping with the COVID-19 pandemic.
A meta-analysis of experimental studies demonstrated that people’s intentions and
behavior change following heightened risk appraisal, including risk perception [15]. Sev-
eral psychological or social factors are reported to be associated with risk perceptions of
COVID-19. Improving perceptions about infectious diseases in society could lead to a
significant improvement in a patient’s well-being and decrease in discrimination [16]. In
addition, prosocial values, trust in government, science, and medical professionals, and
personal knowledge of COVID-19 were all significant predictors of risk perception [17].
Estimating the level of risk perception may be important for the public because that it will
affect the public’s behaviors or coping with COVID-19. It was reported that social distanc-
ing and hand washing were strongly predicted by the perceived probability of personally
being infected, which is a kind of risk perception [18]. Another cross-sectional study in
Mexico demonstrated that both higher level of perceived susceptibility and perceived
severity of COVID-19 were associated with protective behaviors of staying home [19]. On
the other hand, confidence in coping with the COVID-19 pandemic may be associated with
active coping with COVID-19. Confidence in coping is similar to self-efficacy, representing
the individuals’ beliefs that they have the ability to do specific tasks in the future [20].
Previous studies have reported significant associations between having more knowledge
about disease and self-efficacy in coping with SARS [21] along with COVID-19 [22]. There-
Int. J. Environ. Res. Public Health 2021, 18, 1550 3 of 12

fore, further studies are warranted to investigate whether risk perception and confidence
mediate the association between social support and active coping with COVID-19.

1.3. Aims of the Current Study

Adopting adequate coping strategies for infective respiratory disease pandemics
affects both personal health and also the efficacy of infection control for society as a whole.
The aims of the present study were to identify any associations between perceived social
support and active coping with the COVID-19 pandemic, and the potentially mediating
effects of risk perception and confidence. According to above reviews of literatures, it is
hypothesized that perceived social support may be associated with active coping with the
COVID-19 pandemic. Moreover, either confidence or risk perception may be partial or
full mediated the association between perceived social support and active coping with
COVID-19.

2. Methods
2.1. Participants and Procedures
The current study was based on dataset of the Survey of Health Behaviors During
the COVID-19 Pandemic in Taiwan, which was initially reported elsewhere [22]. The
expert meeting was held to develop questionnaires, which were used in this study. In brief,
Facebook users aged ≥20 years and living in Taiwan were recruited into this study between
10 April and 23 April 2020. A Facebook advertisement was posted, which included a
headline, main text, pop-up banner and weblink to the research questionnaire website. The
recruiting advertisement was designed to appear in the “News Feed” of Facebook, which
is a streaming list of updates from the user’s connections (e.g., friends) and advertisers.
A previous study indicated that News Feed advertisements are more effective in terms
of recruitment metrics for research studies [23]. In order to increase its visibility, we also
posted the online advertisement to Line and Facebook groups.
This study was approved by the Institutional Review Board of Kaohsiung Medical
University Hospital (approval no. KMUHIRB-EXEMPT(I)20200011). Although the partici-
pants were not given any incentive for their participation, at the end of the questionnaire
we provided them with weblinks to the online COVID-19 Information Centers of the Tai-
wanese CDC, Kaohsiung Medical University Hospital, and the Medical College of National
Cheng Kung University so they could search for useful information.

2.2. Questionnaires
2.2.1. Perceived Social Support
We estimated the levels of satisfaction with perceived social support using three
questions: “In the past week, did you receive satisfactory support from your (1) family,
(2) friends, and (3) colleagues or classmates?” The responses were graded on a five-point
Likert scale, with scores ranging from 0 (entirely disappointed) to 4 (extremely satisfied).
Higher total scores indicated more satisfaction with their level of perceived social support
during the COVID-19 pandemic. This instrument is reliable and well-validated according
to the supplementary material of previous publication [24].

2.2.2. Active Coping with COVID-19

Liao et al. [25] developed several questionnaires to estimate the protective behavior in
the 2009 influenza A/H1N1 pandemic in Hong Kong. In reference to the above study, we
developed 7 questions to assess the respondents’ level of active coping with the threat of
COVID-19 during their daily lives [26]. The active coping with COVID-19 represented the
coping strategies of problem solving (protective behaviors) against the threat of COVID-
19. These questions asked participants if they: (1) avoided going to crowded places, (2)
maintained good indoor ventilation, (3) cleaned or disinfected their house more often, (4)
washed their hands more often, (5) wore a mask, (6) searched for information on COVID-19,
and (7) avoided clinic visits or had missed appointments at clinics in the past week. The
Int. J. Environ. Res. Public Health 2021, 18, 1550 4 of 12

responses were scored as 0 (“no” or “yes, but not due to COVID-19”) and 1 (“yes, due to
COVID-19”).

2.2.3. Risk Perception toward COVID-19

According to Liao et al. [25], we developed the following question to assess the
severity of current worry towards COVID-19: “Please rate your level of current worry
towards COVID-19.” The severity of current worry towards COVID-19 was rated from
1 (minimal) to 10 (extremely severe). We also developed four additional questions to
evaluate different categories of risk perception: (1) “If you developed flu-like symptoms
tomorrow, would you be worried? Reply: 1 (not at all) to 5 (extremely)”, (2) “In the past
week, have you worried about catching COVID-19? Reply: 1 (not at all) to 5 (extremely)”,
(3) “How likely do you think it is that you will contract COVID-19 over the next month?
Reply: 1 (impossible) to 7 (guaranteed)”, and (4) “What do you think your chances are of
getting COVID-19 over the next month compared with others outside your family? Reply:
1 (impossible) to 7 (guaranteed)”. The current measurement is reported to be reliable and
well-validated according to the supplementary material of previous publication [24].

2.2.4. Confidence against COVID-19

Self-confidence about COVID-19 and perceived confidence in the local government’s
ability to control the COVID-19 pandemic were assessed using the following 2 questions:
(1) “How confident are you that you will overcome the threats of the COVID-19 pandemic?”
and (2) “How confident are you that your city is controlling the COVID-19 pandemic?” The
responses were scored on a five-point Likert scale as follows: 0 (not at all confident), 1 (not
very confident), 2 (neutral), 3 (confident), and 4 (very confident). Higher scores indicated
that the individual was more confident about overcoming the COVID-19 pandemic.

2.2.5. Statistical Analysis

To examine the hypothesized multiple mediation model for the association between
perceived social support and active coping with COVID-19, which was mediated by risk
perception or confidence (Figure 1), the following analyses were conducted using SPSS and
AMOS version 23.0 for Windows (SPSS Inc., Chicago, IL, USA). We examined bivariate
associations among the variables using Pearson’s correlation coefficient (r), followed by
two steps of structural equation modeling (SEM). First, confirmatory factor analysis (CFA)
was used to verify the association between latent variables and their indicators in the
measurement model. Each question was composed of observed variables (indicators) and
latent variables, which indicated perceived social support, active coping with COVID-
19, risk perception, and confidence. Factor loading was used as an index to assess the
scale reliability between indicators and the corresponding latent variables in the CFA. In
addition, Cronbach’s α was calculated to examine the internal consistency reliability. The
range was considered acceptable if Cronbach’s α was >0.5 [27]. To estimate the sample
adequacy of “active coping with COVID-19” in factor analysis, the Kaiser–Mayer–Olkin
(KMO) measure of sampling adequacy and Bartlett testing were applied. A KMO value
of >0.60 and statistically significant value of p < 0.05 from Bartlett testing indicated the
data was adequate for factor analysis [28]. Then, the total variance explained (%) was also
estimated through EFA to estimate the validity of “active coping with COVID-19”.
 for the predictive strength explained in the model.
We used the Sobel test to verify the mediating effect [30]. Furthermore, to test the
adequacy of the model, multiple indices were applied to verify the goodness of fit. For
each of these fit indices, the values indicating an acceptable model fit were as follows:
Goodness of Fit Index (GFI ≥ 0.9); Adjusted Goodness of Fit Index (AGFI ≥ 0.9); root mean
Int. J. Environ. Res. Public Health 2021, 18, 1550 5 of 12
square error of approximation (RMSEA < 0.08); and standardized root mean square resid-
ual (SRMR ≤ 0.08) [31,32].

Figure
Figure1.1.The
Theconceptual
conceptualmodel
modelofofmediating
mediatingeffect.
effect.

Latent variable path analysis with maximum likelihood parameter estimations was
3. Results
used to estimate
3.1. Descriptive the model
Statistics, Factoradequacy
Analysis, and theCorrelation
and the direct/indirect
Matrix effects of perceived social
support on active coping with COVID-19 through risk perception or confidence [29].
Initially, 2031 respondents filled in the online questionnaire. After excluding those
Bootstrapping method with 5000 samples was applied in the path analysis due to the
with missing values (n = 31) and those aged below 20 years (n = 30), a total of 1970
non-normality of the data (Kolmogorov-Smirnov test; p < 0.001). As a multiple mediator
participants (1305 females, 650 males, and 15 transgender) were included in the analysis.
model, both mediators were applied into the model to assess and compare the mediating
The mean
effects. Asage of the
there wasparticipants was 37.81
a relatively high ± 11.00ofyears.
proportion females Thein correlation matrixand
the study cohort withas
significance, mean and standard deviation for each indicator is shown
the Kolmogorov-Smirnov test (p < 0.001) for age was significant, indicating non-normal in Table 1. In
general, active age
distribution, coping
andwith COVIDD-19
gender were alsoisincluded
postivelyincorrelated with mediators’
the multiple risk perception,
model butas
negatively correlated with perceived social support. The values of Cronbach’s
covariates to adjust for their effects on the latent variables. Gender (female, male and α of all
questionnares
transgender) was weretransformed
above 0.5, indicating acceptable range
into two dichotomous dummy [27]. Regarding
variables (malethe
vs.EFA of
female;
“active coping with
and transgender vs. COVID-19”,
female) for the the value of
analysis. Thethe KMO coefficient
standardized estimateswas(beta
0.70,coefficient;
and the
Bartletts’ test of sphericity reached statistical significance
β) were reported for the predictive strength explained in the model. (p < 0.01). It supported the
adequeacy of the sample. The total variance explained (%) of “active coping
We used the Sobel test to verify the mediating effect [30]. Furthermore, to test the with COVID-
19” was at 43.29%,
adequacy which multiple
of the model, was closeindices
to the acceptable
were appliedrangeto of 50%the
verify [33].goodness of fit. For
each of these fit indices, the values indicating an acceptable model fit were as follows:
Goodness of Fit Index (GFI ≥ 0.9); Adjusted Goodness of Fit Index (AGFI ≥ 0.9); root
mean square error of approximation (RMSEA < 0.08); and standardized root mean square
residual (SRMR ≤ 0.08) [31,32].

3. Results
3.1. Descriptive Statistics, Factor Analysis, and the Correlation Matrix
Initially, 2031 respondents filled in the online questionnaire. After excluding those
with missing values (n = 31) and those aged below 20 years (n = 30), a total of 1970
participants (1305 females, 650 males, and 15 transgender) were included in the analysis.
The mean age of the participants was 37.81 ± 11.00 years. The correlation matrix with
significance, mean and standard deviation for each indicator is shown in Table 1. In general,
active coping with COVIDD-19 is postively correlated with risk perception, but negatively
correlated with perceived social support. The values of Cronbach’s α of all questionnares
were above 0.5, indicating acceptable range [27]. Regarding the EFA of “active coping with
COVID-19”, the value of the KMO coefficient was 0.70, and the Bartletts’ test of sphericity
reached statistical significance (p < 0.01). It supported the adequeacy of the sample. The
total variance explained (%) of “active coping with COVID-19” was at 43.29%, which was
close to the acceptable range of 50% [33].
Int. J. Environ. Res. Public Health 2021, 18, 1550 6 of 12

Table 1. The correlation matrix of observed variables.

Varaible Mean SD 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 0.94 0.23 0.13 * 0.14 * 0.16 * 0.18 * 0.09 * 0.06 * 0.18 * 0.1 * 0.18 * 0.11 * 0.04 −0.1 * −0.05 * 0.01 <0.01 −0.01
2 0.88 0.32 - 0.24 * 0.15 * 0.12 * 0.14 * 0.09 * 0.05 * 0.05 * 0.12 * 0.04 <0.01 −0.02 0.01 −0.01 −0.02 −0.001
3 0.67 0.47 - 0.27 * 0.19 * 0.22 * 0.15 * 0.16 * 0.21 * 0.23 * 0.09 * 0.04 −0.09 * −0.07 * −0.02 −0.04 −0.06 *
4 0.92 0.28 - 0.39 * 0.18 * 0.07 * 0.16 * 0.15 * 0.16 * 0.08 * 0.07 * −0.05 * −0.04 0.03 −0.01 −0.02
5 0.89 0.31 - 0.21 * 0.1 * 0.18 * 0.18 * 0.22 * 0.13 * 0.12 * −0.07 * −0.04 0.02 −0.004 −0.02
6 0.76 0.43 - 0.12 * 0.18 * 0.17 * 0.21 * 0.11 * 0.05 * −0.9 * −0.05 * −0.04 −0.05 * −0.004
7 0.17 0.37 - 0.07 * 0.13 * 0.09 * 0.08 * 0.03 −0.1 * −0.04 −0.05 * −0.07 * −0.06 *
8 3.93 0.92 - 0.45 * 0.48 * 0.27 * 0.18 * −0.22 * −0.13 * 0.01 −0.02 <0.01
9 2.59 0.99 - 0.55 * 0.46 * 0.33 * −0.31 * −0.23 * −0.06 * −0.1 * −0.1 *
10 6.14 2.25 - 0.37 * 0.23 * −0.32 * −0.24 * −0.02 −0.05 * −0.06 *
11 3.47 1.14 - 0.57 * −0.39 * −0.27 * −0.09 * −0.09 * −0.09 *
12 3.53 1.28 - −0.23 * −0.17 * −0.04 −0.02 −0.05 *
13 2.41 0.84 - −0.54 * 0.16 * 0.18 * 0.18 *
14 2.32 0.95 - 0.12 * 0.13 * 0.17 *
15 2.98 0.80 - 0.62 * 0.51 *
16 2.90 0.72 - 0.67 *
17 2.71 0.83 -
*: p < 0.05; 1 = Coping-1; 2 = Coping-2; 3 = Coping-3; 4 = Coping-4; 5 = Coping-5; 6 = Coping-6; 7 = Coping-7; 8 = Risk-1; 9 = Risk-2; 10 = Risk-3; 11 = Risk-4; 12 = Risk-5; 13 = Con-1; 14 = Con-2; 15 = Support-1;
16 = Support-2; 17 = Support-3; details of abbreviations are listed in Table 2.
Int. J. Environ. Res. Public Health 2021, 18, 1550 7 of 12

Table 2. Principle component analysis for factors in the conceptual model.

Latent Variables/Observed Variables Factor Loading Cronbach’s Alpha

Active coping with COIVD-19 0.56
Avoid going to crowded places (Coping-1) 0.32
Keep good indoor ventilation (Coping-2) 0.33
Disinfect house more often (Coping-3) 0.50
Wash hands more often (Coping-4) 0.55
Wear a mask (Coping-5) 0.53
Search information of COVID-19 (Coping-6) 0.40
Prevent clinic visits or lost follow up (Coping-7) 0.23
Risk perception 0.71
Develop flu-like symptoms tomorrow (Risk-1) 0.57
Worried about catching COVID-19 last week (Risk-2) 0.76
Rate current level of your worry to COVID-19 (Risk-3) 0.71
How likely you will contract COVID-19 (Risk-4) 0.61
Chances of getting COVID-19 next 1 month (Risk-5) 0.46
Confidence against COVID-19 0.70
Self-confidence overcoming threats of COVID-19 (Con-1) 0.89
Perceived confidence of regional government (Con-2) 0.61
Perceived social support 0.81
Family members (Support-1) 0.69
Friends (Support-2) 0.89
Colleagues or classmates (Support-3) 0.75

3.2. Tests for the Mediation Model and Estimated Coefficient Paths
The first step of the SEM estimated the factor loadings through CFA (Table 2). The re-
sults of the reliability test are also presented, which indicated an acceptable range of
reliability. After adjusting for age and gender, the multiple mediator model was used to
estimate the indirect and direct effects, and the estimated path coefficients are illustrated in
Figure 2. We found that an indirect effect at a value of −0.06 reached statistical significance
(Sobel test: Z = −4.05; p < 0.05), and this was based on the product terms of the path from
perceived social support to risk perception (β = −0.13, p < 0.001) and the path from risk
perception to active coping with COVID-19 (β = 0.49, p < 0.001). On the other hand, the
mediating effect of confidence on the path between perceived social support and active
coping with COVID-19 was not significant (Sobel test: Z = 0.99; p = 0.32). Moreover,
the direct effect from perceived social support to active coping with COVID-19 was not
statistically significant. The significance of the path analysis did not change after adjusting
for age and gender.
These results confirmed the mediating effect of risk perception on the association
between perceived social support and active coping with COVID-19. Based on the model
fit index, the hypothesized model had an adequate model fit index for RMESA (0.068),
GFI (0.927), AGFI (0.902), and SRMR (0.069), indicating the good fit of our hypothesized
mediation model.
 (Con-1)
Perceived confidence of regional government (Con-2) 0.61
Perceived social support 0.81
Family members (Support-1) 0.69
Friends (Support-2) 0.89
Int. J. Environ. Res. Public Health 2021, 18, 1550 8 of 12
Colleagues or classmates (Support-3) 0.75

Figure 2.
Figure Final model
2. Final model of
of mediating
mediating effect
effect indicating
indicating the
the estimated
estimated coefficients
coefficients of
of the
the paths.
paths.
4. Discussion
4. Discussion
4.1. Main Findings of the Current Study
4.1. Main
In theFindings
currentofstudy,
the Current Studyeffect was found in that lower perceived support was
an indirect
In the current
significantly study,
associated withana indirect effect
higher level of was
copingfound
within that lowerwhich
COVID-19, perceived support
was mediated
was
by a significantly
higher level of associated with a higher
risk perception. level of
In addition, a coping with of
direct effect COVID-19,
perceivedwhich
social was me-
support
diated
on copingby awith
higher level of risk
COVID-19 andperception. In addition,
another indirect effect amediated
direct effect of perceived
by confidence social
against
support
COVID-19 ondid
coping with statistical
not reach COVID-19significance.
and another indirect effect mediated by confidence
against COVID-19 did not reach statistical significance.
4.2. Mediating Effect of Risk Perception on the Association between Perceived Social Support and
Active Coping with
4.2. Mediating EffectCOVID-19
of Risk Perception on the Association between Perceived Social Support and
ActiveACoping
higherwith
levelCOVID-19
of risk perception fully mediated the association between lower per-
ceived support and
A higher level of a higher level of active
risk perception fully coping
mediatedwith
theCOVID-19.
associationAlthough
between alower
previous
per-
study indicated that financial security predicted better coping strategies
ceived support and a higher level of active coping with COVID-19. Although a previous against COVID-
19 [14],indicated
study the association betweensecurity
that financial perceived social support
predicted and active
better coping copingagainst
strategies with COVID-19
COVID-
may be different. Perceived social support represents satisfaction with the general sup-
19 [14], the association between perceived social support and active coping with COVID-
port provided by family, friends, and colleagues/classmates, and this represents broader
domains than financial support. In addition, although it did not investigate infective
respiratory diseases, a previous study demonstrated that a higher level of social support
was associated with a lower perceived risk of breast cancer [34]. O’Sullivan reported that
individuals with a higher level of perceived social support may feel that they are relatively
safe, leading to optimism bias, which causes them to believe that they are less likely to
experience negative events [35]. Individuals with such bias may underestimate their risk
of COVID-19; however, further studies are needed to test the effects of optimism bias on
risk perception.
In the current study, we found that a higher level of risk perception was associated
with a higher level of active coping with COVID-19. A previous study investigated the asso-
ciation between risk perception and coping strategies in patients with diabetes, and found
that those who had a low premorbid perception of risks often engaged in diabetes-related
risky behaviors [36]. In addition, a systematic review demonstrated that healthcare workers’
risk perception influenced their behavior towards patients and facilitated risk-mitigating
strategies for emerging acute respiratory infection diseases [37]. Further prospective studies
may provide a better understanding of the temporal relationship between risk perception
and active coping in relation to infective respiratory diseases.
The above findings revealed the importance of risk perception on active coping with
COVID-19; however, perceived social support can compromise the level of risk perception,
leading the interference in active coping with COVID-19. It manifested the controversial
Int. J. Environ. Res. Public Health 2021, 18, 1550 9 of 12

role of perceived social support. Previous study reported that higher level of perceived
social support was associated with less sleep disturbance and suicidal thought, indicating
the protective effect of perceived social support from mental burden [26]. It implicated that
interventions in risk perception and perceived social support are both important for publics
during the COVID-19 pandemic. Specific support to facilitate social interaction is crucial
for those who are socially isolated or quarantined due to infection. Telecommunication
or online gathering should also be promoted for the time in need of social distancing.
Whereas, intervention to enhance publics’ risk perception should not be neglected. Medical
information, news, and governmental policies regarding COVID-19 pandemic should also
be announced widely to enhance the risk perception of publics [17].

4.3. The Non-Significant Mediating Effect of Confidence on the Association between Perceived
Social Support and Active Coping with COVID-19
We found that perceived social support was positively associated with confidence,
whereas the association between confidence and coping with COVID-19 was not significant.
A cross-sectional observational study on medical staff treating patients with COVID-19 in
China demonstrated that levels of social support were significantly associated with self-
efficacy [38]. Self-efficacy represents how well one can execute courses of action required to
deal with prospective situations, and indicates an individual’s belief that they can overcome
obstacles [39]. Although confidence against COVID-19 cannot be entirely compared with
self-efficacy, the association between perceived social support and confidence observed
in the current study deserves further investigation to explore the potential effect of social
support on self-efficacy.
On the other hand, the insignificant association between confidence and active coping
with COVID-19 means that confidence failed to significantly mediate the association
between perceived social support and active coping with COVID-19. Since previous
studies have emphasized the significant association between gathering information and
confidence [22,40], gathering information was only considered as part of active coping
with COVID-19 in the current study. This unexpected finding violated the hypothesis
of the current study. Several factors may implicate this insignificant association. First, it
is possible that other factors involved in active coping with COVID-19 interfered with
the association. On the other hand, the questionnaires of confidence in the current study
may be insufficient to entirely measure the self-efficacy of participants. Therefore, further
development of conceptual model with comprehensively psychological factors and detailed
questionnaires measuring self-efficacy may be helpful to determine the detailed interactions
between confidence and coping strategies against COVID-19.

4.4. Limitations
There are several limitations to the present study. First, possible selection bias may
have confounded the results, as the participants were only recruited through a Facebook
advertisement. Second, causality could only be inferred among the variables due to the
cross-sectional design of this study. Third, several measurements which were crucial in this
scenario were not estimated in the questionnaires, such as level of stigma [16], psychological
distress, and symptoms of post-traumatic stress disorder (PTSD). Finally, COVID-19 had a
limited impact in Taiwan in comparison with other countries, so whether our results can
be generalized to other countries is unclear and warrants further investigation.

5. Conclusions
In the present study, we found that lower perceived social support was indirectly
associated with increased active coping against COVID-19, and that this association was
mediated by higher risk perception. However, we did not identify a mediating effect
of confidence or a direct effect between perceived social support and active coping with
COVID-19. The implication of the current study is that intervention to enhance both
perceived social support and risk perception are necessary for public during COVID-19
pandemic. Moreover, risk perception could be more effective to enhance active coping with
Int. J. Environ. Res. Public Health 2021, 18, 1550 10 of 12

COVID-19 than the confidence against COVID-19. The subjects who were satisfied with
their social support might have had optimism bias that weakened their risk perception
and had a compromising effect on their motivation to cope with COVID-19. Since the
inversed association between perceived social support and risk perception, it is critical to
reduce the effect of optimism bias resulting from perceived social support but not reduce
the social support. To enhance perceived social support, specific resources to facilitate
social interaction are warranted under adequate infection control. Regarding the impact of
the problematic internet use, it is still necessary to promote the telecommunication, online
gathering, or programs of social interaction at the difficult time of social distancing. In order
to strengthen the risk perception and weaken the effect of optimism bias, facilitation of
individuals’ recognition to this pandemic may be beneficial. Timely and correct information
about current threats, policies, and strategies against COVID-19 are necessary and should
be announced by the authorities through traditional (newspapers or television news) and
digital media, such as news feed or livestream thought social software. Public education
on infection control is also necessary both during infectious disease outbreaks and at other
times.
We have several suggestions for further research, which could help extend the findings
of the present study. A paper-and-pencil questionnaire as opposed to a digital question-
naire, along with printed advertisements posted in public areas would be beneficial to also
include non-netizens in the study population. Additional psycho-social factors should
also be considered, such as stigma, discrimination, psychological distress, and symptoms
of post-traumatic stress disorder. Moreover, further studies investigating optimism bias
and self-efficacy using the General Self-Efficacy Scale [41] may be helpful to explore how
people cope with the threats of COVID-19. Finally, the prospective cohort study estimating
the self-efficacy, risk perception, coping with COVID-19, perceived support and related
psycho-social factors (stigma, discrimination, symptoms of PTSD, psychological distress,
vaccine hesitancy, etc.) at different stages of this pandemic are warranted. Importantly,
attitude or hesitancy of vaccine may be associated with risk perception or coping with
COVID-19. Measurements at different stages will be helpful to verify the conceptual model.

Author Contributions: D.-J.L.: Conceptualization, methodology, formal analysis, investigation,

writing—original draft. N.-Y.K.: Formal analysis, data curation, conceptualization. Y.-P.C.: Methodol-
ogy, data curation. C.-F.Y.: Conceptualization, methodology, formal analysis, project administration,
writing—review and editing. Y.-L.C.: Formal analysis, writing—review and editing. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the Institutional Review Board
of Kaohsiung Medical University Hospital (approval no. KMUHIRB-EXEMPT(I)20200011).
Informed Consent Statement: Patient consent was waived due to the design of on-line survey.
Participation in the online survey was voluntary and survey responses were anonymous.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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