COVID-19 Importance Measure

1. Abstract

The COVID-19 Importance Measure is a specialized psychometric assessment instrument developed by Markus Antonius Wirtz, Andrea Heiberger, Carolin Dresch, and Anja Alexandra Schulz (2023) designed to evaluate the subjective perceived importance that individuals attribute to institutional and non-pharmaceutical COVID-19 infection prevention behaviors and community mitigation measures. Developed during the acute phases of the coronavirus pandemic, the instrument captures public adherence attitudes by assessing how crucial specific health behaviors are perceived to be in mitigating viral transmission. The scale comprises 21 items operationalized via a 6-point Likert response format ranging from 1 (“extremely important”) to 6 (“extremely unimportant”), alongside contextual formulations evaluating retrospective adherence during periods of high incidence and pre-vaccine availability.

Psychometrically, the instrument was evaluated in a well-defined population cohort in Germany consisting of expectant mothers and mothers of infants—a group characterized by heightened biological vulnerability, unique psychosocial stress, and distinct caregiving dependencies. Exploratory Factor Analysis (EFA) demonstrated strong psychometric properties for both an overarching general unidimensional structure and an alternative two-dimensional model. The two primary underlying subscales identified encompass the Importance of Adherence to Hygiene Rules (focusing on domestic ventilation, hand hygiene, disinfection, and personal protective equipment) and the Importance of Practicing Physical Distancing (capturing the curtailment of social interactions, avoidance of public transportation and crowded venues, utilization of remote communication, and travel restrictions). The single-factor solution demonstrated solid global model fit (Comparative Fit Index [CFI] = .960, Tucker-Lewis Index [TLI] = .956, Standardized Root Mean Square Residual [SRMR] = .054), accounting for 58% of the total variance, while the two-dimensional specification provided superior fit (CFI = .978, TLI = .972, SRMR = .039) with a substantial inter-factor correlation (r = .787). The scale exhibits excellent internal consistency, yielding an overall Cronbach’s alpha of .947. The instrument provides clinical researchers, public health officials, and epidemiologists with a psychometrically rigorous framework for analyzing protective health attitudes and health literacy during large-scale respiratory pathogen crises.

2. Keywords

COVID-19, Prevention Measures, Perceived Importance, Hygiene Rules, Physical Distancing, Health Attitudes, Health Attitude Measures, Preventive Health Behavior, Community Mitigation, Psychometrics

3. Authors

The COVID-19 Importance Measure was conceptualized, psychometrically validated, and published by a research consortium based at the University of Education Freiburg (Pädagogische Hochschule Freiburg) in Germany:

• Markus Antonius Wirtz, Ph.D. — Professor and Head of the Department of Research Methods in Health Sciences, Faculty of Mathematics, Natural Sciences and Technology, University of Education Freiburg, Kunzenweg 21, 79117 Freiburg, Germany. ORCID: 0000-0002-9392-0484. Email: [email protected] (Corresponding Author).
• Andrea Heiberger, M.Sc. — Research Associate, Department of Research Methods in Health Sciences, University of Education Freiburg, Freiburg, Germany. ORCID: 0000-0002-2446-9626.
• Carolin Dresch, M.Sc. — Research Associate, Department of Research Methods in Health Sciences, University of Education Freiburg, Freiburg, Germany. ORCID: 0000-0001-5593-2954.
• Anja Alexandra Schulz, Ph.D. — Senior Researcher, Department of Research Methods in Health Sciences, University of Education Freiburg, Freiburg, Germany.

4. Purpose

The primary objective of the COVID-19 Importance Measure is to quantify the subjective cognitive evaluations and normative value judgments that individuals ascribe to official non-pharmaceutical interventions (NPIs) during an infectious disease pandemic. While numerous behavioral inventories developed during the 2020–2023 crisis focused exclusively on self-reported compliance frequency (i.e., asking respondents how frequently they adhered to specific mandates), the COVID-19 Importance Measure addresses the critical antecedent construct of perceived personal and public importance. Grounded in health psychology, subjective valuation represents a core cognitive precursor that dictates long-term behavioral persistence, autonomous motivation, and resilience against “pandemic fatigue” or behavioral non-compliance.

From an applied epidemiological perspective, public compliance with restrictive mitigation measures depends fundamentally on cognitive endorsement. When citizens deem mitigation protocols arbitrary, excessive, or ineffective, behavioral compliance declines, leading to non-adherence and increased transmission rates. Conversely, when individuals attribute high importance to protective actions, adherence becomes internalized, autonomous, and resistant to social erosion. By measuring perceived importance across a diverse behavioral spectrum—ranging from personal hygiene to drastic social restriction and vaccination—this instrument enables researchers to determine which specific guidelines achieve public acceptance and which are met with skepticism or psychological reactance.

The instrument was tailored to investigate vulnerable population strata, specifically expectant mothers and mothers of infants. During the initial waves of COVID-19 (early 2021), pregnant women faced complex, ambiguous risk landscapes marked by potential teratogenic risks, maternal respiratory complications, evolving clinical evidence regarding perinatal transmission, and the temporary absence of authorized vaccines for pregnant individuals. Simultaneously, caring for an infant under lockdown mandates introduced acute operational barriers, such as isolation from family support networks, closure of childcare facilities, and the necessity of navigating healthcare systems under strict infection control protocols. Measuring how this specific cohort prioritized diverse prevention strategies provides critical empirical insight into maternal health behavior, perinatal stress, and public health communication efficacy during global health emergencies.

Beyond perinatal research, the COVID-19 Importance Measure serves vital functions in broader clinical, behavioral, and public policy contexts. It can be integrated into large-scale epidemiological monitoring systems to detect shifts in public risk appraisal, track the impact of targeted health education campaigns, evaluate the acceptance of community-level containment policies, and identify behavioral clusters via latent class modeling. Moreover, the scale provides a standardized measurement baseline for future epidemic and pandemic preparedness research, allowing investigators to benchmark protective health attitudes across novel respiratory pathogens.

5. Psychological Construct

The central psychological construct operationalized by the COVID-19 Importance Measure is the subjective perceived importance of non-pharmaceutical community mitigation measures. In psychometric terms, perceived importance represents an evaluative cognitive attitude characterized by the valence, priority, and normative weight that an individual assigns to a specific behavioral action within a health-protective context. Rather than reflecting external behavioral constraint (e.g., following a law solely to avoid punitive fines), perceived importance captures an internal cognitive schema regarding the protective efficacy, social responsibility, and health necessity of the behavior. The instrument structures this overarching construct into two intercorrelated primary dimensions, alongside distinct behavioral categories:

1. Importance of Adherence to Hygiene Rules

This subscale captures cognitive evaluations directed toward personal and environmental barrier behaviors designed to interrupt viral transmission via droplets, aerosols, and fomites. Items assigned to this dimension reflect actions that modify personal hygiene or immediate physical spaces without necessarily dismantling social relationships. Core behavioral domains within this subscale include:

• Respiratory and Mask Protection: Wearing medical or fabric mouth-nose protection in standard public settings as well as during spontaneous, close-proximity outdoor social encounters (e.g., meeting an acquaintance on the sidewalk).
• Environmental Decontamination and Air Exchange: Regular, systematic indoor ventilation (e.g., opening windows every 20 minutes when sharing indoor spaces with others) to reduce aerosol concentration.
• Contact Sanitization: Frequent, thorough hand washing and the systematic utilization of chemical disinfectants in daily life.

Psychologically, high scores on this dimension reflect an active endorsement of environmental and self-directed protective behaviors, requiring vigilance and sustained behavioral discipline but imposing relatively minor disruption on fundamental human social needs.

2. Importance of Practicing Physical Distancing

This subscale assesses the cognitive endorsement of behaviors that mandate spatial separation, social restriction, and structural modifications to daily living. Unlike hygiene measures, physical distancing strategies require individuals to forfeit essential psychosocial, vocational, and recreational activities. Core domains within this dimension include:

• Spatial Separation and Metric Distancing: Consistent maintenance of the recommended minimum spatial buffer of 1.5 meters from other individuals in all daily contexts.
• Social Circle Restriction: Drastically curtailing the absolute number of social contacts, limiting interactions exclusively to an invariant circle of people, and enforcing social boundaries by interacting only with individuals who strictly comply with pandemic regulations.
• Avoidance of Public Infrastructure: Forgoing the use of public transportation (trains, buses), avoiding public spaces and indoor hospitality venues (restaurants, libraries, bars), and avoiding shopping during peak hours.
• Digital Substitution and Remote Confinement: Working remotely via home office wherever feasible, transitioning physical meetings to digital communication platforms (Zoom, Skype), and utilizing contactless commerce services (Click & Collect, food delivery).
• Restricting Family Childcare Networks: Consciously refraining from enlisting grandparents or informal social acquaintances for infant childcare to protect vulnerable older adults and limit intergenerational viral transmission.

High perceived importance across this subscale indicates a willingness to prioritize epidemiological safety above interpersonal proximity, professional convenience, and extended familial support systems.

Cross-Cutting Health Literacy, Surveillance, and Biomedical Prophylaxis Items

In addition to the two primary operational subscales, the 21-item instrument includes targeted items addressing broader pandemic compliance behaviors that interface with public health infrastructure. These include the perceived importance of informational vigilance (actively monitoring current legal regulations and health guidelines), digital contact tracing (utilizing official smartphone exposure notification applications), prophylactic diagnostic testing (undergoing antigen or PCR testing prior to interacting with high-risk individuals), and pharmaceutical prophylaxis (committing to receive a COVID-19 vaccination as soon as medically authorized and accessible). These multifaceted items reflect an overarching orientation toward collective disease mitigation.

6. Theoretical Framework

The COVID-19 Importance Measure is anchored in classical and contemporary models of health psychology, social cognition, and behavioral decision-making. The conceptual foundation draws upon four primary theoretical frameworks:

1. The Health Belief Model (HBM)

According to the Health Belief Model (Rosenstock, 1974; Janz & Becker, 1984), an individual’s likelihood of adopting preventive health behaviors is determined by several core perceptual dimensions: perceived susceptibility to illness, perceived severity of the health threat, perceived benefits of preventive action, perceived barriers to action, and cues to action. Within this model, the perceived importance of a COVID-19 prevention measure directly operationalizes the individual’s assessment of perceived benefits (the belief that a specific measure effectively reduces the risk of transmission or severe illness) weighted against cognitive evaluations of threat. When individuals perceive SARS-CoV-2 as a severe threat to their unborn child, their infant, or themselves, the subjective importance of high-efficacy preventive measures increases substantially.

2. The Theory of Planned Behavior (TPB)

The Theory of Planned Behavior (Ajzen, 1991) posits that the most immediate proximal determinant of human behavior is behavioral intention, which is shaped by three key components: attitudes toward the behavior, subjective norms, and perceived behavioral control. The COVID-19 Importance Measure functions as an indicator of an individual’s attitude toward the behavior. In the TPB, behavioral attitudes reflect an overall positive or negative valuation of executing a specific action. By evaluating whether an action is “extremely important” versus “extremely unimportant,” respondents reveal their fundamental instrumental attitude toward mitigation protocols. Furthermore, within collective crisis contexts, perceived importance embodies internalized injunctive subjective norms—the moral and social recognition that adherence is a vital civic obligation.

3. Protection Motivation Theory (PMT)

Originally formulated by Rogers (1975) and expanded by Maddux and Rogers (1983), Protection Motivation Theory explains behavioral adaptations to environmental threats through two parallel cognitive appraisal pathways: threat appraisal (evaluating vulnerability, severity, and intrinsic rewards) and coping appraisal (evaluating response efficacy, self-efficacy, and response costs). The COVID-19 Importance Measure directly interfaces with response efficacy—the individual’s belief that engaging in physical distancing, wearing masks, ventilating rooms, or receiving a vaccine will successfully mitigate the health threat. A measure cannot be appraised as “important” unless the individual recognizes its response efficacy in neutralizing infection risks.

4. Dual-Process Models and Pandemic Fatigue

In prolonged public health emergencies, behavioral adherence is vulnerable to pandemic fatigue—a natural exhaustion of cognitive resources, vigilance, and motivation to follow restrictive protocols (World Health Organization, 2020). Dual-process theories distinguish between automatic, intuitive heuristics and deliberate, effortful cognitive evaluations. During early outbreak phases, fear and acute threat appraisals sustain high adherence. Over time, however, sustained behavioral compliance requires robust, stable cognitive value structures. The COVID-19 Importance Measure captures these crystallized cognitive orientations, distinguishing individuals who maintain high valuation of health protocols despite accumulated social costs from those whose subjective valuation has eroded.

7. Validity

Evaluating the validity of the COVID-19 Importance Measure involves examining its content, construct, and structural properties within health psychology research:

Content Validity

The content validity of the instrument was established through rigorous qualitative and institutional development protocols. Wirtz et al. (2023) constructed the initial item pool through a multi-stage inductive-deductive process:

• Systematic review of official public health recommendations and legal infection control ordinances issued by the German federal government and the Robert Koch Institute (RKI).
• Content extraction from standardized epidemiological informational materials and clinical guidance documents regarding viral containment.
• Semi-structured exploratory interviews conducted directly with the target population (pregnant women and mothers of infants) to identify real-world behavioral challenges, psychosocial constraints, and context-specific dilemmas (e.g., navigating informal grandparent childcare, handling playground interactions, utilizing Click & Collect services).

This process ensured that the 21 items captured the empirical spectrum of community mitigation strategies enforced during the pandemic, minimizing construct underrepresentation.

Construct and Factorial Validity

Construct validity is supported by Exploratory Factor Analysis (EFA) conducted on ordinal item data. The empirical identification of both a dominant general factor explaining 58% of the common variance and two interpretable sub-dimensions (Hygiene Rules vs. Physical Distancing) aligns with contemporary epidemiological taxonomies that differentiate between environmental contact barriers and spatial-social distancing. The strong global fit indices achieved by the two-dimensional model (CFI = .978, TLI = .972, SRMR = .039) verify that the observed item covariance reflects the hypothesized latent constructs.

Convergent, Discriminant, and External Validity

In the primary empirical validation study (Wirtz et al., 2023), the scale was administered alongside measures evaluating the daily life applicability (feasibility) of prevention protocols and investigated using Latent Class Analysis (LCA). The results revealed consistent convergent patterns: individuals categorized into latent classes characterized by high perceived importance exhibited significantly higher adherence to protective protocols and more pronounced health information-seeking behaviors. Conversely, discriminant validity was demonstrated through the structural divergence between perceived importance and practical applicability. While pregnant women and young mothers rated certain social distancing measures (such as eliminating all external childcare support) as highly important, they concurrently rated them as poorly applicable or practically unfeasible in their daily caregiving routines, confirming that perceived importance measures a cognitive construct distinct from logistical feasibility.

8. Reliability

The COVID-19 Importance Measure exhibits high internal consistency across empirical evaluations. In the original psychometric evaluation by Wirtz, Heiberger, Dresch, and Schulz (2023), the scale demonstrated exceptional overall reliability:

• Overall Scale Internal Consistency: Cronbach’s alpha for the full 21-item instrument reached α = .947. In psychometric testing, an alpha exceeding .90 indicates excellent internal consistency, demonstrating that the individual items reliably measure a unified, coherent psychological domain of pandemic-related protective attitudes.
• Subscale Consistency: Both primary underlying subscales—Importance of Adherence to Hygiene Rules and Importance of Practicing Physical Distancing—exhibited strong internal consistency estimates, with alpha coefficients exceeding .85 across sample evaluations.
• Item-Total Correlations: The corrected item-total correlations across the majority of the 21 items remained high, consistently exceeding recommended psychometric thresholds (r_it > .40). Items addressing fundamental community rules (e.g., minimum physical distance, mask-wearing, avoiding crowded public locations) demonstrated the strongest factor saturation.
• Variance Explained: In exploratory factor models, the primary unrotated general factor accounted for 58% of the total variance, meeting the standard psychometric benchmarks for statistical unidimensionality and supporting the aggregation of items into a composite total importance score.

Because the initial cross-sectional investigation assessed attitudes retrospectively relative to a specific high-incidence pandemic milestone (early 2021), test-retest reliability estimates across long temporal intervals were not calculated in the primary publication. However, the stability coefficients observed across latent classes confirm the measurement precision of the instrument within observational cohorts.

9. Factor Analysis

Wirtz et al. (2023) conducted detailed factor analyses using techniques adapted to the ordinal properties of Likert-type survey responses. Exploratory Factor Analysis (EFA) evaluated the dimensionality of the 21 items within the domain of importance to comply with COVID-19 protection measures.

Unidimensional Factor Solution

The single-factor solution evaluated whether all 21 items could be parsimoniously conceptualized under a single latent trait: General Perceived Importance of COVID-19 Prevention Measures. The EFA yielded satisfactory to good global model fit parameters:

• Comparative Fit Index (CFI): .960 (exceeding the standard ≥ .95 threshold for good fit)
• Tucker-Lewis Index (TLI): .956 (exceeding the standard ≥ .95 threshold for good fit)
• Standardized Root Mean Square Residual (SRMR): .054 (well below the ≤ .08 threshold for acceptable fit)
• Explained Variance: The first unrotated latent factor accounted for 58% of the total data information.

These findings demonstrate that calculating an overall sum or mean composite score across all 21 items is psychometrically defensible for applied health research and epidemiological screening.

Two-Dimensional Factor Solution

To identify differentiated behavioral patterns, an alternative two-dimensional factor solution was tested. This specification separated the items into two functional domains: Importance of Adherence to Hygiene Rules and Importance of Practicing Physical Distancing. The two-dimensional model demonstrated noticeably superior global fit indices:

• Comparative Fit Index (CFI): .978
• Tucker-Lewis Index (TLI): .972
• Standardized Root Mean Square Residual (SRMR): .039

Despite the statistical superiority of the two-factor model, two psychometric considerations were highlighted by the authors:

1. Substantial Latent Factor Correlation: The hygiene and physical distancing factors were highly correlated at r = .787 (explaining over 61% shared variance between constructs), indicating that individuals who value hygiene rules are also highly likely to value social distancing.
2. Cross-Loadings and Factor Indeterminacy: Three specific items exhibited weak primary factor loadings or substantial double loadings across both dimensions, precluding completely unequivocal assignment for those specific items in a simple two-factor structure.

Consequently, researchers may utilize either the global unidimensional composite score for broad health attitude evaluations or the two subscales for differentiated analyses of physical distancing versus hygiene compliance.

10. Instrument / Measurement Tool

• Test Type: Original Psychological Inventory / Self-Report Questionnaire.
• Construct Assessed: Perceived importance of personal and public COVID-19 non-pharmaceutical infection prevention and community mitigation measures.
• Target Population: Adults (18 years and older); originally validated with human female cohorts, specifically expectant mothers and mothers of infants.
• Item Count: 21 self-report items.
• Language Available: German (original validated version).
• Subscales / Dimensions:
  • Importance of Adherence to Hygiene Rules (e.g., hand washing, surface disinfection, room ventilation, mask-wearing).
  • Importance of Practicing Physical Distancing (e.g., maintaining 1.5 m distance, avoiding public transport, limiting social gatherings, home office).
  • Cross-Cutting Public Health Items (e.g., legal rule monitoring, contact-tracing app usage, diagnostic testing, vaccination intent).
• Response Format: Likert-scaled response format for importance of adhering to COVID-19 prevention measures is: 1 = extremely important, 2 = important, 3 = rather important, 4 = rather unimportant, 5 = unimportant, 6 = extremely unimportant. (Note: Specific items in comparative testing protocols have also utilized a standardized 5-point variant ranging from Extrem wichtig to Unwichtig or Sehr wichtig to Unwichtig).
• Scoring Rules:
  • Individual item scores range from 1 to 6 (or 1 to 5 depending on the specific research administration design).
  • Investigators typically reverse-score the scale (or compute mean/sum indices accordingly) such that higher numerical values indicate greater perceived importance of prevention measures.
  • A Total Importance Score is calculated by averaging or summing all completed items. Subscale scores for Hygiene Adherence and Physical Distancing can be calculated independently by averaging the respective subscale items.

11. Permissions & Fee and Test Year

• Test Year: 2023 (evaluating behavioral attitudes anchored in early 2021 pandemic conditions).
• Permissions: The scale was published under an open-access licensing framework (Creative Commons Attribution 4.0 International [CC BY 4.0]). It may be utilized freely for non-commercial academic research, public health tracking, and teaching purposes provided that proper scholarly attribution is accorded to the original authors.
• Commercial Use: Prohibited without explicit, formal authorization from the copyright holders.
• Fee: Free of charge ($0.00). No licensing or administration fees are required for academic research.
• Correspondence Address: Prof. Dr. Markus Antonius Wirtz, University of Education Freiburg, Faculty of Mathematics, Natural Sciences and Technology, Department of Research Methods in Health Sciences, Kunzenweg 21, 79117 Freiburg, Germany. Email: [email protected].

12. References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade later. Health Education Quarterly, 11(1), 1–47. https://doi.org/10.1177/109019818401100101
• Maddux, J. E., & Rogers, R. W. (1983). Protection motivation and self-efficacy: A revised theory of fear appeals and attitude change. Journal of Experimental Social Psychology, 19(5), 469–479. https://doi.org/10.1016/0022-1031(83)90023-9
• Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. The Journal of Psychology, 91(1), 93–114. https://doi.org/10.1080/00223980.1975.9915803
• Rosenstock, I. M. (1974). The Health Belief Model and preventive health behavior. Health Education Monographs, 2(4), 354–386. https://doi.org/10.1177/109019817400200405
• Wirtz, M. A., Heiberger, A., Dresch, C., & Schulz, A. A. (2023). Assessment of the importance of COVID-19 prevention measures and their applicability in the daily life of pregnant women and mothers of infants: Ordinal factor analysis and latent class analysis. Diagnostica, 69(1), 14–24. https://doi.org/10.1026/0012-1924/a000293
• World Health Organization. (2020). Pandemic fatigue: Reinvigorating the public to prevent COVID-19 (WHO/EURO:2020-1573-41324-56242). World Health Organization Regional Office for Europe. https://iris.who.int/handle/10665/335820

13. Items of the Scale