How to Defend COVID-19 in Taiwan? Talk About People's Disease

International Journal of Environmental Research and Public Health

Case Report How to Defend COVID-19 in Taiwan? Talk about People’s Disease Awareness, Attitudes, Behaviors and the Impact of Physical and Mental Health

Chin-Hsien Hsu 1, Hsiao-Hsien Lin 1,* , Chun-Chih Wang 2 and Shangwun Jhang 3

1 Department of Recreation and Sports Management, National Chin-Yi University of Technology, Taichung 41170, Taiwan; [email protected] 2 Department of Recreation and Holistic Wellness, Mingdao University, No. 369, Wen-Hua Rd., Peetow, Changhua 52345, Taiwan; [email protected] 3 Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua 50006, Taiwan; [email protected] * Correspondence: [email protected]

Received: 28 April 2020; Accepted: 15 June 2020; Published: 30 June 2020

Abstract: This study explored awareness, attitudes, and behavior in relation to Coronavirus Disease 2019 (COVID-19) prevention among Taiwanese citizens and their physical and mental health statuses. Through collection of 2132 questionnaire responses in field research, the present researchers analyzed the data using descriptive statistics and various approaches. In conclusion, the public’s high level of willingness to share information, sufficient knowledge of and consensus on epidemic prevention between individuals and families, strict compliance with relevant regulations, effective preventive measures, and adequate public facilities have contributed to control of COVID-19. However, vigilance and awareness of the pandemic in some individuals, epidemic-prevention campaigns, and community-based preventive measures were insufficient. Some citizens subsequently suffered from headaches, anxiety, and mood instability. Furthermore, demographic variables (place of residence, sex, age, and occupation) and physical and mental health status produced various effects on citizens’ awareness, attitude, and behavior regarding epidemic prevention as well as the perceived effect of COVID-19 on physical and mental health.

Keywords: Coronavirus Disease 2019; prevention measures; Taiwan

1. Introduction Coronavirus Disease 2019 (COVID-19) was first discovered in Wuhan, China, although the origins of the virus remain unknown. After the first case was confirmed on 26 December 2019 in Wuhan, the virus rapidly spread, causing a global pandemic. On 9 April 2020, the accumulated number of confirmed cases in China reached 83,249 with a death toll of 3344 in 105 days [1,2]. The daily number of confirmed cases and deaths averaged 826 and 31.8, respectively, indicating the severity of the COVID-19 pandemic. Presently, the pandemic has affected 183 countries with 1,457,989 confirmed cases and 86,730 deaths worldwide [3]. With a mortality rate of 5.95% [4], the virus can damage pulmonary alveoli, leading to respiratory failure and death in severe cases. Currently, the origin of COVID-19 is unknown. COVID-19 can live in the air for a long time, and infected individuals with and without symptoms can both spread the disease [5]. In addition, the transmission of this virus remains unclear. COVID19, the global economy has been substantially affected [6,7]; the pandemic’s severity and the damage subsequently caused are difficult to estimate. Figure1 illustrates the regions a ffected by COVID-19 worldwide and in Taiwan.

Int. J. Environ. Res. Public Health 2020, 17, 4694; doi:10.3390/ijerph17134694 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 4694 2 of 23 Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 2 of 25

Taipei Keelung Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW Lienchiang Taoyuan 2 of 25 New Taipei Hsinchu Kinmen Hsinchu County Yilan Miaoli Taipei Keelung Lienchiang Taoyuan TaichungNew Taipei Hsinchu Kinmen Hsinchu County Changhua Yilan Hualien Penghu Miaoli Nantou Yunlin TaichungChiayi County Chiayi City

Changhua Hualien Penghu TainanNantou Yunlin ChiayiKaohsiung County Taitung Chiayi City

Tainan Pingtung Kaohsiung Taitung

Pingtung

FigureFigure 1. 1.Regions Regions aﬀ affectedected by by COVID-19 COVID-19 across across the the world world (left) (left) and and in Taiwanin Taiwan (up (up to 9to April April 2020). 9, 2020).

Figure 1. Regions affected by COVID-19 across the world (left) and in Taiwan (up to April 9, 2020). DespiteDespite its its proximity proximity to to China, China, Taiwan Taiwan has has successfully successfully controlled controlled COVID-19 COVID-19 because because of of its its geographical advantages and experience gained from the epidemic of severe acute respiratory geographicalDespite advantagesits proximity andto China, experience Taiwan gainedhas successfully from the controlled epidemic COVID of severe-19 because acute of respiratory its syndrome. Since the disease outbreak on 21 January 2020, the Taiwanese government has actively syndrome.geographical Since advantages the disease and outbreak experience on gainedJanuary from 21, the2020, epidemic the Taiwanese of severe government acute respiratory has actively adoptedadoptedsyndrome. various various Since measures measuresthe disease to tocontain outbreak contain the on the virusJanuary virus spread 21,spread 2020, [8 ], [8]the instructed, Taiwaneseinstructed its governmentits citizens citizens in hasin how howactively to to protect protect themselves,themselves,adopted controlled various controlled measures the the healthcare healthcare to contain supply thesupply virus chain, chain, spread and and [8] encouraged ,encouraged instructed academic its academic citizens institutions in institutions how to protect to developto develop antiviralantiviralthemselves, drugs. drugs. controlled By By 9 April,April the 799,healthcare 79 days days after supplyafter the the chain, first first case and case encouraged was was identified, identified, academic the the accumulatedinstitutions accumulated to develop numbers numbers of of confirmedconfirmedantiviral cases drugs.cases and andBy deaths April deaths 9, were 79were days 379 379 after and and the 5, 5, first respectivelyrespectively case was identified, [[99],], averaging the accumulated 4.7 4.7 cas caseses and andnumbers 0.06 0.06 deaths of deaths per perday. day.confirmed These These figures cases figures and are are deaths substantially substantially were 379 lower and lower 5, thanrespectively than those those in [9 in],China, averaging China, where where 4.7 thecas the esnumber and number 0.06 of deaths confirmed of confirmed per cases day. These figures are substantially lower than those in China, where the number of confirmed cases casesis 175.74 is 175.74 times times the number the number in Taiwan in Taiwan and the and number the number of deaths of deaths 5,300 times 5300 timesthe number the number in Taiwan. in is 175.74 times the number in Taiwan and the number of deaths 5,300 times the number in Taiwan. Taiwan.The numbers The numbers of confirmed of confirmed cases cases and anddeaths deaths in Taiwan in Taiwan rank rank 70th 70th and and 92nd, 92nd, respectively respectively among among the The numbers of confirmed cases and deaths in Taiwan rank 70th and 92nd, respectively among the the 183 affected countries (including developed, developing, and underdeveloped countries) [10]. 183183 affected affected countries countries (including developed, developed, developing, developing, and and underdeveloped underdeveloped countries) countries) [10]. These [10]. These These results indicate that the measures against COVID-19 adopted by Taiwan are effective and can resultsresults indicate indicate that that thethe measures against against COVID COVID-19- adopted19 adopted by Taiwan by Taiwan are effective are effective and can and thus can thus thusprovidepr provideovide a areference areference reference forfor for other other countriescountries countries [1 [11].1 [Figure].11 Figure]. Figure 2 demonstrates 2 demonstrates2 demonstrates the numbers the the numbers numbers of confirmed of ofconfirmed confirmed cases cases casesin inTaiwan. in Taiwan. Taiwan.

PopulationPopulation distribution distribution map ofof counties counties and and cities cities DistributionDistribution map of mapcounties of countiesdiagnosed diagnosed in Taiwan in Taiwan in Taiwan LIENCHIANG in Taiwan LIENCHIANG0 LIENCHIANG 13,034 KINMEN 0 0 LIENCHIANG KINMEN KINMEN13,034139,951 PENGHU 0 0 KINMEN PENGHU 139,951105,117 HUALIEN PENGHU0 0 PENGHUHUALIEN 105,117325,706 TAITUNGHUALIEN0 0 HUALIENTAITUNG 325,706216,308 PINGTUNGTAITUNG7 0 PINGTUNG 817,193 TAITUNG 216,308 KAOHSIUNGPINGTUNG 28 KAOHSIUNG 2,773,984 7 PINGTUNG 817,193 TAINANKAOHSIUNG 14 TAINAN 28 1,879,115 CHIAYI COUNTY KAOHSIUNG 2,773,984 TAINAN2 CHIAYI COUNTY 502,007 14 TAINAN 1,879,115 CHIAYI CITY 3 CHIAYI CITY 267,472 CHIAYI COUNTY CHIAYI COUNTY YUNLIN 2 YUNLIN 502,007680,050 CHIAYI CITY4 CHIAYI CITY NANTOU 2 3 NANTOU 267,472493,403 YUNLIN CHANGHUA 4 YUNLINCHANGHUA 680,050 1,271,015 18 TAICHUNG NANTOU 2 NANTOUTAICHUNG 493,403 2,816,667 37 MIAOLICHANGHUA CHANGHUAMIAOLI 544,762 1,271,015 3 18 HSINCHU COUNTYTAICHUNG6 HSINCHUTAICHUNG COUNTY 565,272 2,816,667 37 HSINCHU CITY MIAOLI HSINCHUMIAOLI CITY 449,425 113 544,762 TAOYUAN TAOYUAN HSINCHU COUNTY 43 HSINCHU COUNTY 2,254,363 6 565,272 YILAN YILAN 453,951 HSINCHU0 CITY HSINCHU CITY 449,425 TAIPEI 11 TAIPEI 2,635,286 TAOYUAN 107 TAOYUAN 43 NEW TAIPEI 2,254,363 4,023,620 NEW TAIPEI 86 YILAN YILAN KEELUNG 453,951368,792 KEELUNG 0 0 TAIPEI TAIPEI 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 2,635,2863,000,000 3,500,000 4,000,000 4,500,000 0 20 40 60 80 100 120 107 NEW TAIPEI 4,023,620 NEW TAIPEI 86 KEELUNG 368,792 KEELUNG 0 Figure 2. Confirmed cases of COVID-19 across the world and those in Taiwan (up to April 9, 2020). Figure0 2.500,000Conﬁrmed1,000,000 1,500,000 cases2,000,000 of2,500,000 COVID-193,000,000 3,500,000 across4,000,000 4,500,000 the world and0 those20 in Taiwan40 (up to60 9 April80 2020).100 120

In additionFigureIn addition 2. Confirmed to to the the government, government, cases of COVID citizens citizens-19 across play play athe crucial a world crucial role and in role those pandemic in in pandemicTaiwan control. (up control.toCitizens April 9,must Citizens2020) . mustcomply comply with with the the policies policies implemented implemented byby the the government, government, demonstrated demonstrated awareness awareness through through psychologicalIn addition conceptualization, to the government, perception, citizens judgement, play a crucial and roleimagination. in pandemic They arecontrol. then ableCitizens to must psychological conceptualization, perception, judgement, and imagination. They are then able to complydevelop with appropriate the policies attitudes implemented toward control by measures, the government, develop appropriate demonstrated awareness, awareness and take through develop appropriate attitudes toward control measures, develop appropriate awareness, and take psychological conceptualization, perception, judgement, and imagination. They are then able to develop appropriate attitudes toward control measures, develop appropriate awareness, and take Int. J. Environ. Res. Public Health 2020, 17, 4694 3 of 23 appropriate actions [12–15]. Under such circumstances, the country has the ability to withstand tangible and intangible pressures resulting from the pandemic, respond to global challenges, and adopt appropriate epidemic prevention measures. To assess awareness of epidemic prevention, citizens’ knowledge—including individual, family, and community health awareness and compliance with government instructions [13,16]—can be observed, along with the country’s relevant measures and emergency responses, including notifications on protective measures [15]. Attitudes toward the disease can be determined through observation of individuals’ perceptions and explicit reactions [17–19], such as their vigilance and research in relation to epidemic prevention and health [15]. One can determine individuals’ behaviors in relation to the disease by evaluating their adaptability and personal conduct during the pandemic [20], [21]. For example, research can examine citizens’ vigilance regarding epidemic prevention, their hygiene, their problem-solving skills, and public information [15]. Citizens must maintain their health to achieve epidemic prevention [22]. When individuals experience favorable physical, mental, and social health [23] and their mental states enable them to recognize their own potentials, meet the needs of normal life, and contribute to society [24], their immune systems are likely to improve [25], thereby reducing stress and, subsequently, risks of physical or mental illnesses [26,27]. Therefore, the physical–mental health of citizens is an essential factor in epidemic prevention. To understand an individual’s physical and mental health, researchers should explore his or her physiological, psychological, and spiritual status [28,29], such as emotions and feelings in everyday life or in the workplace, job performance, physical health and reflections, and general attitude toward life. COVID-19 has infected numerous people worldwide. Each country strives to adopt effective measures to tackle the pandemic; prevent transmission; reduce infection risks; restore the economy, protect society, and preserve environments; and offset losses caused during the pandemic [30]. However, the vaccine for this disease has not yet been developed. Therefore, learning from countries that have successfully contained the virus can help governments to make appropriate decisions and overcome current challenges [31]. This study explored Taiwanese citizens in terms of their awareness, attitude, and behavior in relation to COVID-19 prevention, and their physical–mental health. The present researchers then analyzed influential factors influencing the effectiveness of measures imposed by the government. The results provide a reference for the Taiwanese government and governments worldwide to implement and adjust measures against the pandemic.

2. Methods and Instruments

2.1. Study Framework and Hypotheses This research aimed primarily to study awareness, attitudes, and behaviors in relation to COVID-19 prevention among the Taiwanese public as well as their physical and mental health. Subsequently, the researchers compared citizens living in different regions by comparing the numbers of confirmed cases in these areas. Finally, the study analyzed how the government and people in Taiwan have successfully controlled the infection. Taiwan has 22 cities and counties, which are usually divided into five areas according to their locations, populations, resources, and economic activities [32], as shown in Table1.

Table 1. City and county classiﬁcation in Taiwan.

Area County Name Total North Taipei, New Taipei, Keelung, Taoyuan, Hsinchu County, Hsinchu City, Yilan 7 Central Miaoli, Taichung, Changhua, Nantou, Yunlin 5 South Chiayi City, Chiayi County, Tainan, Kaohsiung, Pingtung 5 East Hualien, Taitung 2 islands Kinmen, Lienchiang, Penghu 3 Int. J. Environ. Res. Public Health 2020, 17, 4694 4 of 23 Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 4 of 25

InIn thesethese fivefive regions,regions, wewe investigatedinvestigated awareness,awareness, attitude,attitude, andand behaviorbehavior inin relationrelation toto epidemicepidemic preventionprevention amongamong citizens,citizens, asas wellwell asas theirtheir physicalphysical andand mentalmental health.health. The results helpedhelped thethe researchresearch teamteam toto understandunderstand thethe public’spublic’s awarenessawareness ofof epidemicepidemic prevention,prevention, governmentgovernment measuresmeasures forfor raisingraising suchsuch awareness,awareness, andand approached to prevention of the disease’sdisease’s transmission in Taiwan. TheThe researchresearch questionnaire questionnaire was was designed designed on theon basisthe ofbasis other of studiesother studies [3–38]. The[3–3 researchers8]. The researchers collected datacollected by conducting data by conducting field research, field individualresearch, individual interviews interviews and questionnaire and questionnaire surveys [39 surveys]. Through [39]. dataThrough matching data matching and assessment and assessment [40], summarization, [40], summarization, and analysis, and analysis, the researchers the researchers prepared prepared this manuscriptthis manuscript [41]. [4 With1]. With the the collected collected data, data, this this study study investigated investigated the the e effectsffects ofof citizencitizen awareness, attitudes,attitudes, behaviors,behaviors, andand physicalphysical andand mentalmental healthhealth onon epidemicepidemic prevention.prevention. FigureFigure3 3 depicts depicts thethe frameworkframework ofof thisthis study.study.

Epidemic prevention awareness

H1 Epidemic People prevention National epidemic prevention attitude awareness, attitude, behavior People in different Epidemic and physical and mental health regions H2 prevention status

Physical and mental health

FigureFigure 3.3. Study framework.framework.

Hypothesis 1. Citizens’ awareness, attitudes, and behaviors in relation to epidemic prevention are inconsistent Hypothesiswith their physical 1 (H1). andCitizens’ mental health. awareness, attitudes, and behaviors in relation to epidemic prevention are inconsistentHypothesis with 2. Citizens’ their physical awareness and mentalattitudes, health. and behaviors in relation to epidemic prevention among citizens living in various regions are inconsistent with their physical and mental health statuses. Hypothesis 2 (H2). Citizens’ awareness attitudes, and behaviors in relation to epidemic prevention among citizens2.2. Study living Procedure in various and regions Instruments are inconsistent with their physical and mental health statuses. Facing the overwhelming global pandemic, the government and the people need to take 2.2.appropriate Study Procedure actions and[12– Instruments15] in which the public needs to have a correct understanding of the virus and fully cooperate with the epidemic prevention measures to effectively defend against the threat Facing the overwhelming global pandemic, the government and the people need to take of disease. Additionally, it also requires citizens to exercise to keep themselves in good shape, appropriate actions [12–15] in which the public needs to have a correct understanding of the virus physically and mentally. It was found that most of the current COVD-19 studies explore the and fully cooperate with the epidemic prevention measures to effectively defend against the threat of symptoms caused by the virus, the impects on economic development, the public health risks, and disease. Additionally, it also requires citizens to exercise to keep themselves in good shape, physically other policy-related issues [3–8]. Not many studies have been conducted on the public’s perceptions and mentally. It was found that most of the current COVD-19 studies explore the symptoms caused of the epidemic and defensive behaviors from their perspective. Studies on people’s self-assessment by the virus, the impects on economic development, the public health risks, and other policy-related of their physical and mental health are also few and those that adopt the spatial concepts for analysis issues [3–8]. Not many studies have been conducted on the public’s perceptions of the epidemic and are even rarer. defensive behaviors from their perspective. Studies on people’s self-assessment of their physical and This study originates in the realization that there is a lack of prior studies that explore the mental health are also few and those that adopt the spatial concepts for analysis are even rarer. epidemic prevention awareness and the physical and mental health issues of the public during the This study originates in the realization that there is a lack of prior studies that explore the epidemic COVD-19 epidemic by applying the concept of spatial distribution. Furthermore, although there have prevention awareness and the physical and mental health issues of the public during the COVD-19 been relevant reports focusing on the self assessment of health cognition, attitudes, behaviors, as well epidemic by applying the concept of spatial distribution. Furthermore, although there have been as physical and mental health, none of these studies were conducted in the context of the global relevant reports focusing on the self assessment of health cognition, attitudes, behaviors, as well as pandemic. Researchers will refer to relevant literature [3–37] was reviewed, and the results were physical and mental health, none of these studies were conducted in the context of the global pandemic. examined on the basis of grounded theory [42–45]. The questionnaire items taken from [12–15] and Researchers will refer to relevant literature [3–37] was reviewed, and the results were examined on [35–37] were revised to devise 14 items on epidemic prevention awareness, 8 on epidemic prevention the basis of grounded theory [42–45]. The questionnaire items taken from [12–15] and [35–37] were attitudes, and 16 on epidemic prevention behaviors. Following [32] and [35–37], 16 items on physical and mental health were included. Int. J. Environ. Res. Public Health 2020, 17, 4694 5 of 23 revised to devise 14 items on epidemic prevention awareness, 8 on epidemic prevention attitudes, and 16 on epidemic prevention behaviors. Following [32] and [35–37], 16 items on physical and mental health were included. Five scholars or experts with diverse backgrounds in public health, medicine, recreational sports, and healthcare were invited to help in refining the questionnaire. Respondents answered each item with a score ranging from 1 to 5 according to their attitudes or beliefs about the dimension or topic, with 1 representing minimal feeling and 5 the strongest feeling. In February 2020, 50 copies of the questionnaire were distributed for a pretest, and the results were analyzed using SPSS for Windows 22.0. When KMO > 0.08 and the p-value in Bartlett’s test is less than 0.01 (p < 0.01), this indicates that the scale is suitable for continuing to conduct factor analysis [46], and then the coefficient alpha is greater than 0.80 after the test, indicating that this questionnaire has good reliability [47]. According to the statistical analysis results, there are 14 questions about epidemic prevention awareness. The value of KMO is 0.967, χ2 value yielded from the Bartlett test is 33919.717, df is 91, and the significance value is 0.000 (p < 0.001), suitable for conducting factor analysis. The explained variances of the scale are 70.78%, 13.631%, and 2.783%, and the total explained variance is 77.193%. After factor analysis, all of them are retained, and they are named Epidemic prevention awareness (4), Consensus on decision-making (4), and Emergency response (6) respectively, 3 dimensions containing a total of 14 questions. The α coefficients of the three scales are 0.970, 0.966, and 0.968 respectively, and the α coefficient of the total scale is 0.970. According to the above analysis results, we can know that this questionnaire has good reliability. There are 8 questions about epidemic prevention attitudes. The value of KMO is 0.938, χ2 value yielded from the Bartlett test is 21,256.586, df is 28, and the significance value is 0.000 (p < 0.001), suitable for conducting factor analysis. The explained variances of the scales are 78.696% and 5.071%, and the total explained variance is 83.767%. After factor analysis, all of them are retained, and they are named Perception (4) and Explicit reaction (4), 2 dimensions containing a total of 8 questions. The α coefficients of the two scales are 0.961 and 0.966 respectively, and the α coefficient of the total scale is 0.966. According to the above analysis results, we can know that this questionnaire has good reliability. There are 16 questions about epidemic prevention behaviors. The value of KMO is 0.967, χ2 value yielded from the Bartlett test is 38,088.237, df is 120, and the significance value is 0.000 (p < 0.001), suitable for conducting factor analysis. The explained variances of the scales are 67.489% and 6.201%, and the total explained variance is 73.69%. After factor analysis, all of them are retained, and they are named Daily life adaptability (11), Individual performance (4), 2 dimensions containing a total of 8 questions. The α coefficients of the two scales are 0.967 and 0.969 respectively, and the α coefficient of the total scale is 0.970. According to the above analysis results, we can know that this questionnaire has good reliability. There are 16 questions about influences on physical and mental health. The value of KMO is 0.953, χ2 value yielded from the Bartlett test is 30574.351, df is 120, and the significance value is 0.000 (p < 0.001), suitable for conducting factor analysis. The explained variances of the scales are 55.796%, 11.104%, and 2.697%, and the total explained variance is 69.597%. After factor analysis, all of them are retained, and they are named Psychological status (5), Spiritual status (5), and Attitude and health (6), 3 dimensions containing 16 questions. The α coefficients of the three scales are 0.948, 0.943, and 0.946 respectively, and the α coefficient of the total scale is 0.948. According to the above analysis results, we can know that this questionnaire has good reliability. In summary, based on the above analyses, we can know that all dimensions of epidemic prevention awareness, epidemic prevention attitudes, epidemic prevention behavior, and influences on physical and mental health meet the test requirements, indicating that this questionnaire can be continued to be used for this study, as shown in Table2. Int. J. Environ. Res. Public Health 2020, 17, 4694 6 of 23

Table 2. Design on awareness, attitudes, and behaviors in relation to epidemic prevention and the public’s physical and mental health.

Dimension Subdimension Subject (M) Cronbach’α Unstable mood(3.02), feelings of anxiety and panic(3.28), reduced ability(2.67), Psychological status (5) 0.943–0.948 reduced enthusiasm(2.91), and limited time(2.94) Physical and mental health Headaches(2.62), fatigue(2.57), pain(2.44), Spiritual status (5) 0.942–0.943 back pain(2.32), and insomnia(2.32) Stomach ache(2.25), increased smoking frequency(2.17), irritability(2.36), lack of Attitude and health (6) 0.942–0.946 confidence(2.15), loss of life purpose(2.25), and suicidal thoughts(2.05) Effectiveness of epidemic prevention campaigns(3.88), family influences on individual prevention habits(3.88), Epidemic prevention awareness (4) 0.967–0.970 formation of prevention habits in families(4.15), and prevention consensus between the public and individuals(4.18) Epidemic prevention campaigns(4.18), campus prevention campaigns(4.13), family Consensus on decision-making (4) 0.966–0.967 Epidemic prevention awareness prevention consensus(4.19), and prevention consensus among interviewees(4.19) Effect of prevention campaigns on health(3.97), the effects of prevention measures(3.98), the effectiveness of self-protection awareness(3.93), prevention Emergency response (6) 0.967–0.968 campaigns in public spaces(4.02), prevention campaigns in the media(3.95), and prevention facility installment in public spaces(4.04) Compliance with prevention measures(4.14), increased prevention vigilance in daily life(4.09), increased Perception (4) 0.959–0.961 campus prevention vigilance(4.13), and the effects of prevention knowledge on Epidemic prevention attitude infection rate(4.1) Prevention information acquisition(3.99), compliance with teachers’ epidemic prevention advice(4.04), compliance with Explicit reaction (4) 0.929–0.962 public space prevention measures(4.07), and informational research of prevention knowledge(3.93) Adequate compliance with the epidemic prevention measures(3.99), active compliance with prevention measures(4.03), correct naming of all prevention processes(3.79), compliance with public space regulations(4.04), wearing of masks(4.08), consultation of experts and Daily life adaptability (11) 0.967–0.968 scholars for advice(3.92), consultation of online media for advice(3.88), reporting to Epidemic prevention behavior parents or teachers(3.76), reporting to relatives or friends(3.84), active maintenance of personal hygiene(3.93), active maintenance of cleanliness at home(3.94), medical waste recycling(3.97) Sharing of prevention knowledge(3.76), reminding persons of inappropriate individual behavior(3.67), active Individual performance (4) 0.967–0.969 community cleaning(3.67), reminding persons of inappropriate public behavior(3.68)

Since the discovery of this phenomenon in January 2020, the researchers began to review relevant literature and develop a research process and framework. The samples were collected between March 1 and April 10, 2020. At the beginning of the sampling period, as the epidemic was unfolding, it was difficult to collect questionnaire information personally due to the government order and health concerns. Therefore, the DoSurvey online platform was used to retrieve questionnaire information. The participants were required to provide identification information while submitting their responses. As the epidemic eased down gradually from April 1, researchers conducted supplementary surveys using the field survey method. In addition to visiting each site to understand the development of the epidemic in each region, it also allowed the use of the sampling method to simultaneously collect information from the locals. A total of 2132 questionnaires were obtained and the results were compiled using the SPSS for Windows 22.0 statistical package. Int. J. Environ. Res. Public Health 2020, 17, 4694 7 of 23

In order to obtain more in-depth information, the researcher collected and analyzed questionnaire samples, and then designed the semi-structured interview content for the interview survey. After asking for people’s consent and consent, using Line and Faecbook social networking software interviewed a total of 10 scholars, owners, general public and students from different regions with health and hygiene expertise or research experience to provide them with sample analysis Insights into the results. After the participants verified the accuracy of the recorded content, the researchers integrated the information of the questionnaire, analyzed the results, and cmpleted the research paper through the processes of induction, organization and analysis [41]. Finally, a multivariate validation analysis method was adopted to combine the information obtained from different research subjects, theories, and methods, to validate multiple data from multiple perspectives, and compare the results of different studies [39,40,42–44] in order to acquire accurate knowledge and implications, and to investigate the current status of public awareness, attitudes, and behaviors associated with epidemic prevention, and their perceptions of physical and mental health, as shown in Table3.

Table 3. Respondent background and interview topics.

Gender Age Occupation Area Gender Age Occupation Area male 22 student northern male 55 education central female 22 Service industry south male 38 Tourism central male 21 student northern female 56 administration staﬀ northern male 45 education islands male 57 administrative northern female 42 ﬁnancial south female 24 student east Level interview topics description How do you know your epidemic awareness, decision consensus, and resilience? Where does local Cognition information generally come from? How do you know your epidemic alert settings and information? Where do local information attitude generally come from? How do you know your personal anti-epidemic attitude and self-protection measures? Where do behavior local information generally come from? What is the impact of the epidemic on an individual’s physical and mental health? What industry Physical and has the greatest impact? Where does the local information generally come from? mental health Based on the above, which one has the greatest impact on people, regions, and occupations? And give your opinion?

2.3. Study Scope and Limitations The study investigated the impact on epidemic cognition, attitudes, behaviors, as well as physical and mental health during the period of COVIS-19 by targeting the local residents in different regions of Taiwan. However, in the midst of epidemic prevention, out of the concern of the risk of asymaptomatic transmission of the disease [6,7], the government advocated policies and guidelines such as avoiding going out, participating in crowd activities, and taking public transportation, as well as maintaining one meter distance between people, and taking body temperature and wearing masks at all times [8]. The public’s fear of infection further reduced their willingness to contact with people [48] and decreased opportunities for interpersonal interaction thereby greatly affecting the sample collection. Therefore, in order to successfully collect enough samples, a survey using online platform was performed. However, due to the above-mentioned restrictions and people’s concerns, as well as the constraints in transportation and funding, the difficulty in coordinating work and interview times, and the different experiences in using the online survey platform, people’s willingness to be interviewed were affected, which further influenced the information and proportion of the sample presentation. Although the associated limitations may impact the findings, we believe that there is still research value after supplementing the information with the multivariate research approach [39,40,42–44]. Hence, if the above discrepancies occur, we will provide corrections and suggestions for subsequent studies. Int. J. Environ. Res. Public Health 2020, 17, 4694 8 of 23

3. Analysis of Results

3.1. Demographics People in Central Taiwan are friendly, and most of them exercise habitually. Because of a change in ideas regarding procreation, the area has seen a sharp rise in its female population [46]. Although the students in this area have sufficient free time, their intentions to travel are low due to budget restraints. Most of the respondents were residents of Central Taiwan (52.9%), female (60.5%), aged 20 years ≤ (50.1%), and were college or university students (79.6%). Most exercised and routinely engaged in recreational activities but had few opportunities to travel (69.4%). Most of the respondents reported satisfactory physical and mental health (91.9%). Since the first confirmed diagnosis, the Taiwanese government has paid considerable attention to the potential threat of the COVID-19 epidemic. In addition to establishing the Central Epidemic Command Center, the government monitors the epidemic status in the entire country and applies responsive measures accordingly. It utilizes television, the Internet, and social media to broadcast news on the current epidemic status and epidemic prevention information for people to reference in preventing the disease. Many of the participants had acquired information on epidemic prevention from the Internet (44.8%) and television (46.4%), as shown in Table4.

Table 4. Sample analysis.

Area No. % Gender No. % Occupation No. % Northern 711 33.3% male 842 39.5% student 1505 70.60% Central 1129 52.9% female 1290 60.5% Restaurant Catering 131 6.10% South 211 9.9% Age No. % tourism 28 1.30% East 25 1.2% Under 20 1068 50.1% Leisure sport 19 0.90% islands 58 2.7% 21–30 769 36.1% Marketing media 13 0.60% Health status No. % 31–40 105 4.9% Teachers and civil servants 21 1% Good health 1960 91.9% 41–50 111 5.2% Legal administration 13 0.60% other illnesses 29 1.4% 51–60 57 2.7% Human Resources 17 0.80% chronic 53 2.5% Over 61 22 1% Finance/Insurance/Accounting 34 1.60% general 43 2% education level No. % Business services 53 2.50% new coronary 20 0.9% Elementary 19 0.9% real estate 23 1.10% general trauma 27 1.3% Junior 56 2.6% Transportation 10 0.50% Aviation industry and Leisure behavior No. % Senior 301 14.1% 2 0.10% petroleum industry yes 260 12.2% universities 1697 79.6% E-commerce 3 0.10% no 1872 87.8% Over institute 59 2.8% Export trade 13 0.60% Epidemic Travel habits No. % No. % Industrial manufacturing 38 1.80% prevention message yes 1482 69.4% Oral 118 5.5% Machining 27 1.30% Agriculture, Forestry and no 652 30.6% Proclamation 42 2% 10 0.50% Fisheries Health No. % newspapers 105 4.9% Soldiers and police 22 1% education knowledge family 115 5.4% TV 989 46.4% Human agency 4 0.20% School 246 11.5% Online social platform 878 41.2% Retail and wholesale 34 1.60% Government 299 14.0% Computer communication 22 1% Mass media 956 44.8% Performance of art 10 0.50% Online social 516 24.2% Housekeeping freelance 80 3.80% platform

3.2. Analysis of Awareness, Attitudes, and Behaviors in Relation to Epidemic Prevention among Taiwanese Nationals and of Their Physical and Mental Health Statuses Compared with other cases [35–37], the government actively invests in health and hygiene education, attaches importance to the people’s body and mind, and helps strengthen immunity in Taiwan [24–26]. Tis was a reason for the success of prevention in Taiwan, setting an example for other countries [11]. Descriptive statistics were applied to determine Taiwanese citizens’ physical and mental health as well as their awareness, attitudes, and behaviors in relation to epidemic prevention. The results revealed inﬂuential factors leading to the success of prevention measures adopted by the Taiwanese government, as listed in Figure4. Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 9 of 25

30.6 Proclamatio Agriculture, Forestry and no 652 42 2% 10 0.50% % n Fisheries Health education No. % newspapers 105 4.9% Soldiers and police 22 1% knowledge 46.4 family 115 5.4% TV 989 Human agency 4 0.20% % Online 11.5 41.2 School 246 social 878 Retail and wholesale 34 1.60% % % platform Governmen 14.0 299 Computer communication 22 1% t % 44.8 Mass media 956 Performance of art 10 0.50% % Online 24.2 social 516 Housekeeping freelance 80 3.80% % platform

3.2. Analysis of Awareness, Attitudes, and Behaviors in Relation to Epidemic Prevention Among Taiwanese Nationals and of Their Physical and Mental Health Statuses Compared with other cases [35–37], the government actively invests in health and hygiene education, attaches importance to the people’s body and mind, and helps strengthen immunity in Taiwan [24–26]. Tis was a reason for the success of prevention in Taiwan, setting an example for other countries [11]. Descriptive statistics were applied to determine Taiwanese citizens’ physical and mental health as well as their awareness, attitudes, and behaviors in relation to epidemic prevention. The results revealed influential factors leading to the success of prevention measures adopted by the Int. J. Environ. Res. Public Health 2020, 17, 4694 9 of 23 Taiwanese government, as listed in Figure 4.

Causes of infection-foreign infected people return to Taiwan Cause of infection-domestic infection Number ofNumber diagnoses

Cause of infection-domestic infection FigureFigure 4. 4.Leading Leading to to prevention prevention success success in in Taiwan. Taiwan.

EEffectsffects onon citizens’citizens’ awareness, attitude, attitude, and and behavior behavior regarding regarding pandemic pandemic prevention prevention and andtheir theirphysical physical and andmental mental health health varied varied among among regions, regions, supporting supporting Hypothesis Hypothesis 1. We 1. Wediscovered discovered that thatconsensus consensus between between individuals individuals and and families, families, pub publiclic facilities, facilities, epidemic epidemic-prevention-prevention knowledge, knowledge, and andindividual individual preventive preventive actions actions were wereadequate. adequate. People Peoplewere willing were willingto shareto information share information with one withanother one and another follow and government follow government instructions. instructions. However, However, epidemicepidemic-preventionprevention awareness, awareness, epidemicepidemic-preventionprevention campaigns, campaigns, vigilance vigilance in relation in relation to the to thepandemic, pandemic, and and community community hygiene werewere insuinsufficient.fficient. Some Some individuals individualswere were subsequently subsequentlya affectedffected by by physical physical and and mental mental health health problems problems suchsuch as as headaches, headaches, anxiety, anxiety, and and mood mood instability, instability, as as shown shown in in Table Tab5le. 5.

Table 5. Analysis of awareness, attitudes, and behaviors in relation to epidemic prevention among Taiwanese nationals and of their physical and mental health statuses.

Highly Recognized M Low Recognition M Total Score Actual Score prevention consensus Eﬀectiveness of Epidemic between the 4.18 epidemic 3.88 20 16.10 Epidemic prevention awareness individuals prevention campaigns prevention awareness Consensus on family campus 4.19 4.13 20 16.70 decision-making prevention consensus prevention campaigns prevention facility Eﬀect of prevention Emergency response installment in 4.04 3.93 30 23.89 campaigns on health public spaces Compliance with increased prevention Epidemic Perception 4.14 4.09 20 16.45 prevention measures vigilance in daily life prevention attitude compliance with informational Explicit reaction teachers’ epidemic 4.07 research of 3.93 20 16.03 prevention advice prevention knowledge active compliance with prevention reporting to parents Epidemic Daily life adaptability 4.08 3.76 55 47.17 measures and or teachers prevention behavior wearing of masks Sharing of active Individual performance 3.76 3.67 20 14.77 prevention knowledge community cleaning feelings of anxiety Psychological status 3.28 reduced ability 2.67 25 14.81 Physical and and panic mental health Spiritual status headaches 2.62 insomnia 2.57 25 12.27 Attitude and health irritability 2.36 suicidal thoughts 2.05 30 13.22

Compared with their counterparts, people living in Northern Taiwan demonstrated greater concerns regarding the cleanliness of surroundings. The northern region is the major transportation hub, where most imported cases were confirmed. Moreover, prevention information was slightly insufficient, and some individuals had poor knowledge and vigilance of epidemic prevention. The accumulated number of confirmed cases in Taiwan was 379. Despite a few domestic cases, Taiwan has controlled the disease under control because of favorable individual and family prevention consensus, comprehensive prevention facilities in public spaces, strict compliance with individual and Int. J. Environ. Res. Public Health 2020, 17, 4694 10 of 23 public prevention policies, mask wearing among most citizens, and willingness to share information [49]. Although the interviewees felt uncomfortable due to mental stress, Taiwan did not restrict people from going out [50], so their daily lives and work performance were not affected. Therefore, the epidemic control in Taiwan is stable.

3.3. Analysis of Awareness, Attitudes, and Behaviors in Relation to COVID-19 Prevention among Citizens in Various Regions and of their Physical–Mental Health On the basis of the country’s experience with the 2003 SARS outbreak, the Taiwanese government established an independent health administration, and each county or city government set up an official health management branch for medical management and healthcare knowledge promotion, thereby reinforcing national health education and fostering a satisfactory sense of leisure and healthcare practices. In addition, the government manages and controls surgical mask distribution through convenience stores and pharmacies across Taiwan, and it utilizes social media platforms to transmit epidemic information in real time. However, due to the gap between urban and rural development in Taiwan, the level of health and hygiene education and the implementation of decision-making are different [50], and regional resources and lifestyles are different, which affects the effectiveness of epidemic prevention. The success of epidemic prevention depends on efforts by individuals, families, and communities and their compliance with imposed measures and instructions [15]. Consensus between individuals and communities helps to improve policy effectiveness [22–31]. The effectiveness of prevention measures varied among cities and counties; some cities even had zero confirmed cases. However, patterns regarding the numbers of confirmed cases did not vary according to economic, social, and environmental characteristics in different regions. To descriptive statistics, the t test, and analysis of variance (ANOVA) were performed to compare the effects of place of residence, sex, age, occupation, and physical–mental health status on participants’ awareness, attitude, and behavior regarding COVID-19 prevention and the perceived effects on their physical and mental health.

3.3.1. Northern Area As presented in Table6, for epidemic prevention awareness, the highest score was in family habits and consensus (4.3) and the lowest in epidemic-prevention campaign and the eﬀectiveness of such advocacy in maintaining health (3.9). With attitudes, cooperation with policies had the highest score (4.2) and epidemic prevention information gathering the lowest (3.9). For behaviors, voluntarily wearing masks received the highest score (4.2) and community cleaning the lowest (3.6). Regarding physical and mental health, they were the most notable for anxiety and headaches (3.2) but least notable for suicide ideation (2.0). These results are partially consistent with ﬁndings in [35–37]. Int. J. Environ. Res. Public Health 2020, 17, 4694 11 of 23

Table 6. Of awareness, attitudes, and behaviors in relation to COVID-19 prevention among citizens in Northern area and of their physical–mental health.

Background Cognition Attitude Behavior Physical and Mental Health Family habits (4.3) Voluntarily wearing masks (4.2) Anxiety (3.2) Cooperation with policies (4.2) High cognition(M) Family consensus (4.3) Gathering medical waste (4.0) Headache (3.2) Compliance with public measures (4.1) Public measures (4.1) Sharing information (3.8) Irritability (2.4) Conveying epidemic prevention Epidemic-prevention campaign (3.9) Capability (2.6) Alertness (4.0) information (3.8) Low cognition(M) Campus epidemic prevention (4.1) Lumbago (2.3) Information gathering (3.9) Home cleaning (3.9) Advocacy to promote health (3.9) Suicidal ideation (2.0) Community cleaning (3.6) Epidemic prevention advocacy (3.8:4.1) * Epidemic prevention steps (3.8:4.2) * Media information (3.8:4.1) * Mood (3:3.1) * family habits (3.8:4.1) * personal execution (3.8:4.2) * Different gender teacher suggestions (3.9:4.2) * pain sensitivity (2.6:2.4) * self-epidemic prevention (4:4.4) * seeking solutions (3.7:4.0) * (t) public measures (3.9:4.3) * eating disorders (2.5:2.2) * health protection (3.8:4.0) * wear mask (3.8:4.2) * health search information (3.8:4.1) lack of confidence (2.4:2.0) * public protection (3.8:4.3) * management (3.8:4.2) * Emotions (21–30,3 > 51–60) * Teachers (51–60 > 41–50) * Stress (Under 20,21–30 > 51–60) * relatives and friends for help (51–60 > pain sensitivity (Under Campus epidemic prevention (51–60 > Under 20,21–30,41–50) * Family habits (Under 20,21–30,41–50 > 51–60) * Different age (F) Under 20,21–30) *, information sharing (51–60 > Under 20,21–30,31–40,41–50 > 51–60) * insomnia (41–50 > 51–60) * teacher suggestions (51–60 > 41–50) * 20,21–30,41–50) * lack of self-confidence (Under epidemic prevention supervision 20,41–50 > 51–60) * (51–60 > Under 20,41–50) * seeking death (Under 20 > 21–30) * Epidemic prevention steps (1,6 > 3) * Different Health status(F) personal execution (1,4,2,5,6 > 3) * pain sensitivity (6 > 1) * 1: Good seeking solutions (1 > 3) * insomnia (4,3 > 1,2,5) * 2: common cold public consensus (1,4,2,5,6 > 3) * Campus epidemic prevention (1,2,5,6 > 3) * wear mask and health management indigestion (3 ,6 > 1,5) * 3: new coronavirus health protection (1,4,2,5,6 > 3) * media information (1,2,6 > 3) * (1,4,2,5,6 > 3) * eating disorders (3 > 1) * 4. chronic disease public protection and facilities (1,6 > 4,3) * public measures (1,6 > 4,3) * information sharing (1,4,2,5,6 > 3) * lack of self-confidence (4 > 1) * 5. common trauma epidemic prevention supervision seeking death (4,6 > 1,2) * 6. other (1,4,2,5,6 > 3) * * p < 0.01. Int. J. Environ. Res. Public Health 2020, 17, 4694 12 of 23

Further analysis revealed no significant differences according to occupation. However, women reported significantly (p < 0.01) stronger feelings than men in the following items: for attitudes, epidemic-prevention campaign, family habits, self-epidemic prevention, health protection, and public measures; for awareness, media information, teachers’ advice, public measures, and epidemic prevention information searching; regarding behaviors, epidemic prevention steps, cooperation, seeking solutions, wearing masks, and health management. Men reported stronger feelings (p < 0.01) for the following items: on physical and mental health, anxiety, headache, eating disorder, and feeling lost. The respondents significantly differed by age (p < 0.01) in their scores on the following items: for awareness, campus epidemic prevention and teachers’ advice; on behaviors, seeking help from teachers, families, or friends, sharing information, and sense of justice. Those aged 50, ≤ 51, and 51–60 years were particularly sensitive to the items related to attitudes, awareness, ≥ and behaviors, respectively. The reported physical and mental health of respondents significantly (p < 0.01) affected their scores for the following items: for attitudes, public consensus, health protection, and public measures; regarding awareness, campus epidemic prevention, media information, and public measures; on behaviors, epidemic prevention steps, cooperation, seeking solutions, voluntarily wearing masks, sharing information, and sense of justice. Compared with other respondents, those infected with COVID-19 exhibited low scores in all the awareness, attitude, and behavior dimensions and reported more health problems such as insomnia, indigestion, and overeating; the public also reported higher pain sensitivity, insomnia, sense of loss, and suicidal tendency. The results indicate that residents in Northern Taiwan have satisfactory family hygiene habits and epidemic prevention consensus. They are strongly cooperative with policies, have high epidemic protection awareness, and wear surgical masks voluntarily. Therefore, they are a major reason for the successful defense against the outbreak. However, because of a discrepancy between the content of epidemic-prevention campaign and policies and their implementation, a flaw has appeared in the line of defense, causing people in Northern Taiwan to exhibit anxiety and headaches. Northern Taiwan exhibits the highest number of confirmed diagnoses in the entire country. Additional analysis revealed that older adults exhibit the most severe symptoms related to this outbreak. Because of advocacy by news media worldwide, residents aged 51 years or above have paid considerable attention to the epidemic; those aged no higher than 50 years, who frequently use electronic devices because of work or lifestyle, are particularly sensitive to information pertinent to the epidemic. Women in this region are particularly conscious of their personal hygiene and exhibit strong cognitions on diseases as well as self-protection awareness. Therefore, they are particularly strong in epidemic prevention awareness, attitudes, and behaviors and are maintaining their health more easily than men during the epidemic. Those infected with COVID-19 are low in their awareness, attitudes, and behaviors pertinent to epidemic prevention and are prone to insomnia, indigestion, and overeating (Figure5). Overall, although flaws exist in the epidemic prevention policy planning and execution in Northern Taiwan, the residents of this region are highly aware of the epidemic and are highly cooperative with epidemic prevention policies. The area is a key to successful epidemic prevention but also a place that can incur an increase in the number of confirmed cases. Correct epidemic prevention measures should be conveyed in the region to maintain the hygiene level of the residents, thereby further enhancing the effectiveness of epidemic prevention.

3.3.2. Central Area As Table7 presents, for epidemic prevention attitudes, the respondents from Central Taiwan scored epidemic-prevention campaign and campus consensus the highest (4.2) and personal consensus the lowest (2.7). With awareness, life alertness had the highest score (4.1) and epidemic prevention information gathering the lowest (3.0). Regarding behaviors, voluntarily wearing masks received the highest score (4.0) and personal and community cleaning the lowest (3.6). In physical and mental Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 13 of 25

The results indicate that residents in Northern Taiwan have satisfactory family hygiene habits and epidemic prevention consensus. They are strongly cooperative with policies, have high epidemic protection awareness, and wear surgical masks voluntarily. Therefore, they are a major reason for the successful defense against the outbreak. However, because of a discrepancy between the content of epidemic-prevention campaign and policies and their implementation, a flaw has appeared in the line of defense, causing people in Northern Taiwan to exhibit anxiety and headaches. Northern Taiwan exhibits the highest number of confirmed diagnoses in the entire country. Additional analysis revealed that older adults exhibit the most severe symptoms related to this outbreak. Because of advocacy by news media worldwide, residents aged 51 years or above have paid considerable attention to the epidemic; those aged no higher than 50 years, who frequently use electronic devices because of work or lifestyle, are particularly sensitive to information pertinent to the epidemic. Women in this region are particularly conscious of their personal hygiene and exhibit Int.strong J. Environ. cognitions Res. Public on Health diseases2020, 17as, 4694well as self-protection awareness. Therefore, they are particularly 13 of 23 strong in epidemic prevention awareness, attitudes, and behaviors and are maintaining their health more easily than men during the epidemic. Those infected with COVID-19 are low in their awareness, health,attitudes, these and respondents behaviors werepertinent the most to epidemic notable forprevention anxiety (3.2) and but are least prone notable to insomnia, for sense indigestion, of loss (2.0). Theseand overeating results are (Figure partially 5). consistent with the ﬁndings in [35–37].

Diffusion factors: Ther e i s a gap bet ween t he cont ent of ant i - epi demic advocacy and t he cont ent of deci si on- making and implementation Factor of success: Hi gh cons ens us on f amil y hygi ene habi t s and epi demic pr event i on, st r ong awar eness of decision-maki ng coor di nat i on, hi gh awar enes s of per sonal epi demic pr event i on, and act i ve wear i ng mask Physical and mental health effects: Anxi et y, headache Differences in background factors: People over the age of 51 pay more attention to the development of the epidemic, and people under the age of 50 are more sensitive to the information of the epidemic because they have more access to information software equipment. Women are sensitive to epidemic prevention cognition, attitude, behavior, etc. People with new pneumonia have low acuity due to epidemic awareness, attitudes, behaviors and other issues, so they are prone to problems such as insomnia, indigestion, and overeating. Figure 5. OfOf key factors for epidemic prevention in north Taiwan.

Further.Overall, analysis although revealed flaws exist no significantin the epidemic difference prevention between policy occupations. planning However, and execution women in reportedNorthern significantlyTaiwan, the strongerresidents (p of< 0.01)this region feelings are than highly men aware in the of following the epidemic items: and for awareness,are highly personalcooperative and with family epidemic habits andprevention consensus, policies. public The consensus, area is a healthkey to management,successful epidemic and awareness prevention of publicbut also epidemic a place preventionthat can incur facilities; an increase in attitudes, in the media number information, of confirmed teachers’ cases. advice, Correct and epidemic public measures;prevention and measures in behaviors, should epidemicbe conveyed prevention in the region steps, to alertness, maintain epidemicthe hygiene prevention level of the information residents, gathering,thereby further and health enhancing management. the effectiveness The men reportedof epidemic stronger prevention. feelings (p < 0.01) for the following items: in physical and mental health, insomnia, headache, indigestion, reduced enthusiasm, and overeating. 3.3.2.The Central responses Area significantly differed by age (p < 0.01) for the following items: for awareness, personal and family consensus and epidemic prevention acceptance; for behaviors, alertness, teachers’ As Table 7 presents, for epidemic prevention attitudes, the respondents from Central Taiwan advice, and public measures; and regarding behaviors, epidemic prevention steps and seeking solutions. scored epidemic-prevention campaign and campus consensus the highest (4.2) and personal Respondents of each age group felt particularly different about the following health-related items: consensus the lowest (2.7). With awareness, life alertness had the highest score (4.1) and epidemic emotions, work ability, enthusiasm, pain sensitivity, insomnia, and sense of loss. Those aged 20 years prevention information gathering the lowest (3.0). Regarding behaviors, voluntarily wearing≤ masks were particularly sensitive to the items related to attitudes, awareness, and behaviors and were received the highest score (4.0) and personal and community cleaning the lowest (3.6). In physical particularly prone to be influenced by emotions, work ability, enthusiasm, and pain sensitivity. and mental health, these respondents were the most notable for anxiety (3.2) but least notable for Those aged 21–50 years reported problems related to work ability, enthusiasm, headache sensitivity, sense of loss (2.0). These results are partially consistent with the findings in [35–37]. insomnia, and sense of loss. Differences in physical and mental health were unrelated to awareness, attitudes, or behaviors (p > 0.01) but were significantly (p < 0.01) related in the following items related to health: emotions and enthusiasm. Moreover, healthy respondents and those diagnosed with chronic disease or having other symptoms differed significantly in the strength of the effects of emotions and enthusiasms. The results suggest the authorities of the Central Taiwan have actively advocated epidemic prevention policies and campus epidemic prevention. Residents are highly alert against COVID-19 in their daily lives and voluntarily wear masks, contributing to successfully preventing the spread of the epidemic. The flaws exist in that the residents who have weak attitudes regarding personal cleaning, epidemic prevention consensus, and information gathering, and community cleaning has been insufficient. These cause most residents of the region to be anxious and caused 64 citizens in this region to be diagnosed with COVID-19. Int. J. Environ. Res. Public Health 2020, 17, 4694 14 of 23

Table 7. Of awareness, attitudes, and behaviors in relation to COVID-19 prevention among citizens in Central area and of their physical–mental health.

Background Cognition Attitude Behavior Physical and Mental Health Voluntarily wearing masks (4.0) Epidemic-prevention campaign (4.2) Life alertness (4.2) Anxiety (3.0) Consulting the media for advice (3.9) High cognition Campus consensus (4.2) Compliance with public epidemic Mental weakness (2.6) Reminding persons of inappropriate public Media outreach (4.0) prevention (4.1) Irritability (2.7) behavior (3.8) Personal consensus (2.7) Compliance with public regulations (3.7) Enthusiasm (2.6) Information gathering (3.0) Low cognition Advocacy to promote health (3.9) Personal cleaning (3.6) Indigestion (2.3) Personal cleaning (3.6) Public measures (3.9) Community cleaning (3.6) Sense of loss (2.1) personal and family habits (3.5:4.0) * Insomnia (2.4: 2.2) * personal (2.9:2.7) * Epidemic prevention steps (3.7:3.9) * Media information (3.8:4.3) * Pain (2.8: 3.0) * Different gender family (3.8:4.3) * consensus with the personal execution (3.8:4.2) * teachers ’suggestions (3.7:4.2) * Indigestion (2.8: 2.3) * (t) public (3.8:4.4) * seeking solutions (3.8:4.2) * public measures (3.8: 4.2) * reduced enthusiasm (2.4:2.3) * health protection (3.9:4.4) * health management (3.8:4.2) * eating disorders(2.4:2.1) * public protection and facilities (3.7:4.2) * Emotions (Under 20 > Over 61) * work ability (Under 20,21–30,31–40,41–50 Personal consensus (Under 20 > 21–30) > Over 61) *enthusiasm (Under Sensitivity (Under 20 > 21–30) family consensus (Under 20 > 21–30) * Epidemic prevention steps (Under 20 > 21–30) * 20,21–30,31–40,41–50 > 51–60) * Different age (F) teacher suggestions (Under 20 > 21–30) * epidemic prevention advocacy seeking solutions(Under 20 > 21–30) * pain sensitivity (Under 20 > public measures(Under 20 > 21–30) * acceptance (Under 20 > 21–30) * 21–30,51–60,6) * insomnia (31–40,41–50, Over 61 > 51–60) * lack of self-confidence (41–50 > 51–60) * Different Health status(F) 1: Good 2: common cold Emotions(1,4,6 > 5) 3: new coronavirus NS NS NS enthusiasm(4,6 > 5) 4. chronic disease 5. common trauma 6. other * p < 0.01. Int. J. Environ. Res. Public Health 2020, 17, 4694 15 of 23

As shown in Figure6. further analysis revealed that residents aged 20 years, who are highly ≤ active and competent at grasping and collecting information from the Internet, are particularly sensitive to items related to epidemic prevention awareness, attitudes, and behaviors. However, because they Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 17 of 25 interact with others frequently, their likelihood of becoming infected with COVID-19 is particularly high.T Theyhe results are more suggest sensitive the toauthorities emotions, of work the ability,Central enthusiasm, Taiwan have and actively pain than advocated those in otherepidemic age groups.prevention Women policies in thisand region campus are epidemic particularly prevention aware of. R theiresidents personal are highly hygiene alert and against are particularly COVID-19 strongin their in daily epidemic lives preventionand voluntarily awareness, wear masks, attitudes, contributing and behaviors; to successfully therefore, they preventing maintain the their spread health of morethe epidemic. easily than The men flaws during exist the in epidemic. that theAlthough residents most who of have the residentsweak attitudes have remained regarding healthy personal and activelycleaning, coordinate epidemic withprevention the epidemic consensus, prevention and information measures, gathering their emotions, and community and job enthusiasm cleaning arehas alsobeen a ﬀinsufficient.ected; this isTh becauseese cause of most industry residents stagnation of the andregion the to loss be ofanxious job opportunities and caused in64 thecitizens face ofin this the epidemic,region to be which diagnosed impact with the residents’ COVID-19. quality of life.

Diffusion factors: Per sonal cl eanl i ness and epi demic pr event i on cons ens us , epi demic pr event i on i nf or mat i on collection attitude is weak, and community cleanliness is insufficient. Factor of success: Ant i -epidemic policy promotion and active anti- epi demic on campus, r esi dent s ar e al er t t o l i f e, and act i vel y wear mask

Physical and mental health effects: anxi et y Differences in background factors: The epidemic prevention cognition, attitude, and behavior cognition under the age of 20 are sensitive, but the mood, work ability, enthusiasm, and pain are strong. Women's awareness of epidemic prevention, attitudes, and behaviors are more sensitive and easy to maintain health. The people actively cooperated with the decision-making, but the mood and work enthusiasm were affected by the epidemic factors. FigureFigure 6.6. OfOf keykey factorsfactors forfor epidemicepidemic preventionprevention inin centralcentral Taiwan.Taiwan.

Overall,As shown the in residentsFigure 6. offurther Central analysis Taiwan revealed are lacking that residents in their personal aged ≤ 20 cleaning years, who and are epidemic highly preventionactive and consensus,competent attitudesat grasping in gatheringand collecting information, information and awarenessfrom the Internet, of community are particularly cleaning. However,sensitive to the items local governmentsrelated to epidemic have actively prevention advocated awareness, epidemic attitudes, prevention and behaviors. policies and H campusowever, epidemicbecause they prevention. interact with The residentsothers frequently, are highly their alert likelihood in their dailyof becoming lives and infected wear masks with COVID voluntarily.-19 is Therefore,particularly this high. area They is a keyare tomore successful sensitive epidemic to emotions, prevention work ability, but also enthusiasm, a spot where and an pain increase than in those the numberin other ofage conﬁrmed groups. Women cases may in this occur. region Improvements are particularly must aware be made of intheir personal personal cleaning, hygiene epidemic and are preventionparticularly consensus, strong in attitudesepidemic inprevention gathering awareness, information, attitudes, and awareness and behaviors; of community therefore, cleaning they tomaintain enhance their epidemic health more prevention easily alertnessthan men andduring behaviors the epidemic. among Although the residents, most of thereby the residents reinforcing have epidemicremained prevention. healthy and actively coordinate with the epidemic prevention measures, their emotions and job enthusiasm are also affected; this is because of industry stagnation and the loss of job 3.3.3.opportunities South Area in the face of the epidemic, which impact the residents’ quality of life. AsOverall, displayed the residents in Table8, of for Central epidemic Taiwan prevention are lacking attitudes, in amongtheir personal the respondents cleaning from and Southernepidemic Taiwan,prevention personal consensus, and street attitudes visit consensusin gathering had information, the highest and score awareness (4.3) and mediaof community outreach cleaning. had the lowestHowever, score the (3.9). local For governments awareness, have the highest actively score advoc wasated in epidemic life alertness prevention and compliance policies and with campus public measuresepidemic (4.2)prevention. and the lowestThe residents in information are highly gathering alert in (4.0). their Regarding daily lives behaviors, and wear voluntarily masks voluntarily. wearing masksTherefore, was this scored area highest is a key (4.2) to successful and sense epidemic of justice prevention (3.5) lowest. but With also physical a spot where and mentalan increase health, in thesethe numbe respondentsr of confirmed were the cases most may notable occur. for emotion-relatedImprovements must problems be made (3.2) in but personal least notable cleaning, for suicidalepidemic ideation prevention (2.1). consensus, These results attitudes are partially in gathering consistent information, with the ﬁndings and awareness in [35–37 ].of community cleaning to enhance epidemic prevention alertness and behaviors among the residents, thereby reinforcing epidemic prevention.

3.3.3. South Area As displayed in Table 8, for epidemic prevention attitudes, among the respondents from Southern Taiwan, personal and street visit consensus had the highest score (4.3) and media outreach had the lowest score (3.9). For awareness, the highest score was in life alertness and compliance with public measures (4.2) and the lowest in information gathering (4.0). Regarding behaviors, voluntarily Int. J. Environ. Res. Public Health 2020, 17, 4694 16 of 23

Table 8. Of awareness, attitudes, and behaviors in relation to COVID-19 prevention among citizens in Southern area and of their physical–mental health.

Background Cognition Attitude Behavior Physical and Mental Health Personal consensus (4.3) Campus alertness (4.2) Emotions (3.2) Voluntarily wearing masks (4.2) High cognition Street visit consensus (4.3) Compliance with public Mental weakness (2.5) Community cleaning (3.7) Public measures (4.1) measures (4.2) Overeating (2.2) Epidemic-prevention campaign (4.0) Life alertness (4.1) Ability deterioration (2.6) Teachers’ reactions (3.7) Low cognition Campus epidemic Acquiring information Lumbago (2.1) Sense of justice (3.5) prevention (4.2) from media (4.0) Suicidal ideation (1.9) Media outreach (3.9) Diﬀerent gender Public consensus (3.7:4.2) * NS NS NS (t) Stress (31–40 > 21–30) * Insomnia (21–30 > Under 20) * Diﬀerent age (F) NS NS Expert advice(Under 20 > 21–30) * pain sensitivity (21–30 > Under 20) * eating disorders(21–30 > Under 20) * * p < 0.01.

Further analysis revealed no significant difference between occupations or physical and mental health status. However, women reported significantly stronger feelings than men for public consensus in the awareness dimension (p < 0.01). No significant differences were identified for any other item. Seeking expert assistance differed significantly by age (p < 0.01). Age also influenced scores for the following health-related problems (p < 0.01): stress, insomnia, pain sensitivity, and overeating. Those aged 20 years were particularly sensitive to the items related to behaviors. ≤ Those aged 21–30 years were prone to insomnia, pain sensitivity, and overeating. Those aged 31–40 years experienced stress. According to the results, the residents of Southern Taiwan have attained high personal and street visit consensus as well as high alertness in daily living. They are willing to comply with public measures and wear masks voluntarily. These are keys to successful epidemic prevention. However, media outreach is insufficient, and the residents lack the attitudes required for gathering information on epidemic prevention and the sense of justice needed to report inappropriate behaviors that inhibit epidemic prevention. These are flaws in the defense against COVID-19; they negatively affect the emotions of most of the respondents in this region and have led to 56 residents being diagnosed with COVID-19. Further analysis revealed that women in this region are particularly conscious of their personal hygiene and particularly strong in epidemic prevention awareness, attitudes, and behaviors; therefore, they have maintained their health more effectively than men. Those aged 20 years, who are highly ≤ capable of collecting information from the Internet, are particularly sensitive to epidemic prevention behaviors. However, those aged 21–30 years plan diverse activities and interact with others frequently; consequently, their likelihood of becoming infected with COVID-19 is particularly high. They are also prone to insomnia, pain sensitivity, and overeating. Those aged 31–40 years report higher stress compared with younger respondents, as indicated in Figure7. Overall, the media outreach in Southern Taiwan is insufficient, and residents lack the attitudes required to gather information on epidemic prevention and the sense of justice needed to report inappropriate behaviors. However, strong personal and street visit consensus, high alertness in daily living, compliance with public health measures, and voluntary mask wearing have contributed to successful epidemic prevention. Authorities in Southern Taiwan should enhance media outreach, and residents should remind each other to comply with the epidemic prevention measures and actively collect information pertinent to epidemic prevention, thereby improving the epidemic prevention alertness and behaviors of families and individuals and further reinforcing epidemic prevention.

3.3.4. East Area As Table9 indicates, for epidemic prevention attitudes, family habits, personal consensus, campus advocacy, and family consensus had the highest score (3.9) and public facilities of epidemic prevention Int. J. Environ. Res. Public Health 2020, 17, 4694 17 of 23 had the lowest score (3.4). With awareness, cooperation awareness and campus alertness ranked highest (4.1) and compliance with public measures (3.2) lowest. Regarding behaviors, the highest score was in compliance with epidemic prevention measures (3.9) and the lowest in community cleaning (3.0). For physical and mental health, anxiety was most notable (3.6) and suicidal ideation least notable (1.8).Int. J. Environ. These resultsRes. Public are Health partially 2020, 17 consistent, x FOR PEER with REVIEW the ﬁndings in [35–37]. 19 of 25

Diffusion factors: The medi a di s s eminat i on i s not enough, t he public's attitude towards epidemic prevention i nf or mat i on col l ect i on and t he s ens e of j us t i ce t o accuse ot her s of i mpr oper epi demic pr event i on ar e not enough Factor of success: Personal consensus and street vi si t consensus are high, residents are alert in life, willing t o abi de by publ i c epi demi c pr event i on measur es, and act i vel y wear masks f or pr ot ect i on Physical and mental health effects: Emoti onal Differences in background factors: Women' s awar eness of epi demic pr event i on, at t i t udes, and behavi or s ar e mor e sensi t i ve and eas y t o mai nt ai n heal t h. The awareness of epidemic prevention behavior under the age of 20 is relatively strong, the infection rate is high, and there are problems of insomnia, pain sensitivity, and overeating. The pressure of 31-40 is even greater. FigureFigure 7. 7.OfOf key key factors factors for for epidemic epidemic preventionprevention in in southern southern Taiwan. Taiwan.

Overall, the media outreach in Southern Taiwan is insufficient, and residents lack the attitudes requiredTable to 9. gatherOf awareness, information attitudes, on andepidemic behaviors prevention in relation and to COVID-19the sense preventionof justice needed among citizensto report in inappropriateEastern area behaviors. and of theirHowever, physical–mental strong personal health. and street visit consensus, high alertness in daily living, compliance with public health measures, and voluntary mask wearing have contributed to successful Physical and Mental Background Cognition Attitude Behavior epidemic prevention. Authorities in Southern Taiwan should enhance media outreach, and residentsHealth should remind each Familyother habits to (3.9)comply with the epidemic prevention measures and actively collect Personal consensus (3.9) information pertinent Campusto epidemic advocacy prevention, (3.9) thereby improving the epidemic prevention alertness and Family consensus (3.9) behaviors of families andPublic individuals consensus (3.7) and further reinforcing epidemic prevention. Compliance with epidemic Anxiety (3.6) Advocacy to promote health (3.7) Cooperation awareness (4.1) High cognition prevention measures (3.9) Headache (2.8) Public epidemic-prevention Campus alertness (4.1) Sense of justice (3.1) Sense of loss (2.0) 3.3.4. East Area campaign (3.7) Media epidemic-prevention campaign (3.7) As Table 9 indicatesPublic epidemic-prevention, for epidemic prevention attitudes, family habits, personal consensus, campus advocacy, andfacilities family (3.7) consensus had the highest score (3.9) and public facilities of epidemic Propaganda and Epidemic Life alertness (3.8) Community cleanliness (3.0) Decreased ability (2.6) preventionLow cognition had the lowestPrevention score (3.5) (3.4). WithComply awareness, with public cooperationTeacher awareness response, reflection and campusInsomnia (1.9) alertness ranked highest (4.1)Public and anti-epidemic compliance facilities with (3.4) anti-epidemic public measures measures (3.2) (3.2from) relativeslowest and. friendsRegarding (3.4) Suicide behaviors, (1.8) the Different Health status(F) highest1: Good score was in compliance with epidemic prevention measures (3.9) and the lowest in 2: common cold Public places(1 > 3,2) * community3: new coronavirus cleaning (3.0). For physical and NSmental health, anxiety NS was most notable (3.pain6 sensitivity(4) and suicidal> 1) * media outreach(1 > 3,2) * ideation4. chronic disease least notable (1.8). These results are partially consistent with the findings in [35–37]. 5. common trauma 6. otherFurther analysis revealed no significant differences between people of different genders, age groups, or occupations. However, a strong correlation* p < 0.01. was identified between physical and mental health and feelings regarding public measures and media outreach in the awareness dimension (p < 0.01)Further. The respondents analysis revealed differed no significant considerably differences in their between pain sensibility people of diaccordingfferent genders, to their age reported groups, orhealth occupations. status; health However,ier ones a strongwere particularly correlation sensitive was identified to the betweenitems related physical to awareness, and mental whereas health andthose feelings diagnosed regarding as having public a cold measures were particularly and media sensitive outreach to in pain. the awareness dimension (p < 0.01). The respondents differed considerably in their pain sensibility according to their reported health status; healthierTable ones 9. O weref awareness, particularly attitudes, sensitive and behaviors to the items in relation related to toCOVID awareness,-19 prevention whereas among those citizens diagnosed as havingin Eastern a cold area were and particularly of their physical sensitive–mental to health pain.. According to the analysis, residents in Eastern Taiwan report satisfactory family habits, personal Physical and Background Cognition Attitude Behavior and family consensus, campus advocacy, cooperativeness, and campus alertness. Moreover,mental they health wear masks voluntarily andFamily comply habits (3.9) with all epidemic prevention measures. These contribute to the Personal consensus (3.9) Campus advocacy (3.9) Family consensus (3.9) Compliance with Public consensus (3.7) Cooperation Anxiety (3.6) epidemic prevention High cognition Advocacy to promote awareness (4.1) Headache (2.8) measures (3.9) health (3.7) Campus alertness (4.1) Sense of loss (2.0) Sense of justice (3.1) Public epidemic- prevention campaign (3.7) Media epidemic- prevention campaign (3.7) Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 20 of 25

Public epidemic- prevention facilities (3.7) Community Life alertness (3.8) Propaganda and Epidemic cleanliness (3.0) Decreased ability Comply with public Prevention (3.5) Teacher response, (2.6) Low cognition anti-epidemic Public anti-epidemic reflection from Insomnia (1.9) measures (3.2) facilities (3.4) relatives and friends Suicide (1.8)

(3.4) Different Health status(F) 1: Good 2: common cold Public places(1 > 3,2)* pain NS NS 3: new coronavirus media outreach(1 > 3,2)* sensitivity(4> 1)* 4. chronic disease 5. common trauma 6. other *p < 0.01. Int. J. Environ. Res. Public Health 2020, 17, 4694 18 of 23 According to the analysis, residents in Eastern Taiwan report satisfactory family habits, personal and family consensus, campus advocacy, cooperativeness, and campus alertness. Moreover, they successfulwear epidemic masks voluntarily prevention and and comply zero with confirmed all epidemic COVID-19 prevention diagnoses measures. in These the region. contribute However, to the insufficientsuccessful public epidemic epidemic prevention prevention and facilities, zero confirmed unsatisfactory COVID-19 attitudes diagnose ins in complying the region. with However, public measures,insufficient and unfavorable public epidemic community prevention cleanliness facilities, are unsatisfactory flaws that require attitudes improvement. in complying with public Furthermeasures, analysis and unfavorable revealed that community the local cleanliness authorities are flaws in the that Eastern require Taiwanimprovement. emphasize public measures andFurther intensively analysis utilize revealed media that tothe advocate local authorities epidemic in the prevention, Eastern Taiwan contributing emphasize to thepublic zero confirmedmeasures diagnoses and asintensively well as the utilize satisfactory media to physicaladvocate andepidemic mental prevention, health of contributing the residents. to However,the zero confirmed diagnoses as well as the satisfactory physical and mental health of the residents. However, the region relies on tourism industries and is faced with a reduced number of tourists because of the the region relies on tourism industries and is faced with a reduced number of tourists because of the epidemic,epidemic, affecting affect localing livelihoods local livelihood ands industriesand industries and and causing causin anxietyg anxiety among among residents. Moreover, Moreover, they arethe enduringy are enduring the common the common cold andcold highand high pain pain sensitivity, sensitivity as, as shown shown in in Figure Figure8 .8.

Hidden crisis: Publ i c ant i -epidemic facilities are not enough, t he publ i c obs er ves publ i c ant i -epi demic meas ur es , and communit y cl eanl i nes s i s not enough Factor of success: Famil y habi t s , per s onal cons ens us , campus advocacy, f amil y cons ens us i s hi gh, coor di nat i on awar enes s , campus al er t nes s , initiative to wear mask protection, willing to follow all epidemic prevention measures. Physical and mental health effects: anxi et y Differences in background factors: There is no cognitive difference between gender, age and occupation. Healthy people pay more attention to public epidemic prevention facilities and media to disseminate information, but feel anxious. FigureFigure 8. Of 8. keyOf key factors factors for for epidemic epidemic prevention prevention in east in east Taiwan. Taiwan.

Again, theAgain, residents the residents of Eastern of Eastern Taiwan Taiwan exhibit exhibit satisfactory satisfactory family family habits, habits, personalpersonal and and family family consensus,consensus, campus campus advocacy, advocacy, cooperativeness, cooperativeness, and and campus campus alertness. alertness.Moreover, Moreover, they wear wear masks masks voluntarilyvoluntarily and comply and comply with allwith epidemic all epidemic prevention prevention measures. measures. These These contribute contribute to the the successful successful epidemic prevention in the area. However, public epidemic prevention facilities, unsatisfactory epidemic prevention in the area. However, public epidemic prevention facilities, unsatisfactory attitudes in complying with public measures, and unfavorable community cleanliness are potential attitudes in complying with public measures, and unfavorable community cleanliness are potential risks in the line of defense against the outbreak. Local authorities must improve epidemic prevention risks in thefacilities, line of enforce defense compliance against the with outbreak. the public Local authoritiesepidemic prevention must improve measures, epidemic and preventionpromote facilities,community enforce compliance cleaning awareness with the public to further epidemic strengthen prevention the epidemic measures, prevention and promote alertness community and cleaningbehaviors awareness of tofam furtherilies and strengthen individuals the and epidemic thereby maintain prevention the current alertness status. and behaviors of families and individuals and thereby maintain the current status.

3.3.5. Offshore Islands As presented in Table 10, regarding epidemic prevention attitudes, family epidemic prevention, personal consensus, and public consensus had the highest scores (4.3) and family habits had the lowest score (3.8). For awareness, life and campus alertness received the highest score (4.2) and epidemic prevention knowledge and teachers’ advice the lowest (3.9). With behaviors, the highest score was in compliance with public measures and voluntarily wearing masks (4.1) and the lowest in suggestions from friends and family and community cleaning (3.6). For physical and mental health, anxiety was most notable (3.1) and suicidal ideation the least (1.8). These results are partially consistent with the findings in [35–37]. No significant differences were noted between people of different genders, age groups, or occupations. However, a strong correlation was identified between physical and mental health and feelings regarding public epidemic prevention facilities and media outreach in the awareness dimension (p < 0.01). The respondents differed considerably in their pain sensibility according to their health status; healthy respondents were particularly sensitive to items related to awareness, whereas those diagnosed as having a cold were particularly sensitive to pain. Int. J. Environ. Res. Public Health 2020, 17, 4694 19 of 23

Table 10. Of awareness, attitudes, and behaviors in relation to COVID-19 prevention among citizens in Oﬀshore islands and of their physical–mental health.

Cognition Attitude Behavior Physical and Mental Health Family epidemic prevention, personal Compliance with public measures, Anxiety (3.1) consensus, public Life alertness, campus High cognition voluntarily wearing masks (4.1) Headache (3.0) consensus (4.3) alertness (4.2) Sense of justice (3.9) Indigestion (2.5) Advocacy to promote health (3.9) Family habits (3.8) Campus epidemic Epidemic prevention Sense of urgency (2.9) Suggestions from friends and Low cognition prevention (4.2) knowledge, teachers’ advice Insomnia (2.6) family, community cleaning (3.6) Public epidemic (3.9) Suicidal ideation (2.1) prevention (4.0) Pain sensitivity (2.6:3.2) * Indigestion (2.2:2.7) * abnormal diet (2.4:2.5) * Different gender Epidemic NS Message sharing(3.8:3.9) * insomnia (2.4:2.8) * (t) Prevention(4.3:3.5) * emotional instability (2.3:2.8) * confidence (2.5:2.4) * life goals (2.4:2.5) * Epidemic prevention steps (Under Media information (Under 20,21–30,31–40,41–50 > Over 61) * Pain sensitivity (4 > Under Different age (F) NS 20,21–30,31–40,41–50 > Over epidemic prevention supervision 20,21–30,31–40) * 61; Under 20 > 31–40) * (Under 20,21–30,31–40,41–50 > abnormal diet (41–50 > Under 20) * Over 61) * * p < 0.01.

Accordingly, satisfactory family epidemic prevention, personal and public consensus, life and campus alertness, and residents’ compliance with public measures and voluntary mask wearing have contributed to the successful epidemic prevention and zero confirmed COVID-19 diagnoses on the offshore islands. However, insufficient family epidemic prevention habits, lack of epidemic prevention knowledgeInt. J. Environ. Res. and Public willingness Health 2020, to 17,seek x FORhelp PEER fromREVIEW teachers, family, and friends, and unsatisfactory22 of 25 community cleanliness may impede epidemic prevention efforts. Further analysis revealed that regardless of their gender,gender, ageage group,group, oror occupation,occupation, thethe residentsresidents highlyhighly valuevalue publicpublic epidemicepidemic preventionprevention facilitiesfacilities andand understandunderstand thethe rolerole ofof mediamedia propagationpropagation inin depth;depth; thesethese contributecontribute toto thethe successfulsuccessful epidemicepidemic preventionprevention andand zerozero confirmedconfirmed diagnosesdiagnoses asas wellwell asas toto satisfactorysatisfactory physicalphysical andand mentalmental health.health. However, the islands, which heavily rely on tourism,tourism, areare confrontedconfronted withwith aa reducedreduced numbernumber ofof touriststourists becausebecause ofof thethe epidemic,epidemic, whichwhich aaffectsffects livelihoodslivelihoods andand locallocal industriesindustries and and causes causes anxiety anxiety among among the the residents. residents. Moreover, Moreover, the the residents residents are are susceptible susceptible to headaches,to headaches, and and those those diagnosed diagnosed as havingas having a cold a cold are are particularly particularly sensitive sensitive to painto pain (Figure(Figure9). 9).

Hidden crisis: The f amil y' s epi demic pr event i on habi t s, t he peopl e' s epi demic pr event i on knowl edge, t he desi r e t o seek t he assi st ance of t eacher s, and t he hel p of r el at i ves and f r i ends ar e not hi gh, and t he communit y i s not cl ean enough. Factor of success: Famil y epi demic pr event i on, per s onal cons ens us and publ i c cons ens us ar e hi gh, l i f e al er t nes s , and campus al er t nes s ar e s t r ong, compl y wi t h public epidemic prevention, and actively wear mas ks f or pr ot ect i on.

Physical and mental health effects: headache Differences in background factors: There is no difference in gender, age, and occupational cognition. Healthy people pay more attention to public epidemic prevention facilities and media to disseminate information, and the pain is more sensitive.

Figure 9. Of key factors for epidemic prevention in oﬀshore islands Taiwan. Figure 9. Of key factors for epidemic prevention in offshore islands Taiwan.

Once again, satisfactory family epidemic prevention, personal and public consensus, life and campus alertness, and compliance with public measures and voluntary mask wearing have contributed to the successful epidemic prevention on the offshore islands. However, insufficient family epidemic prevention habits along with people’s lack of epidemic prevention knowledge and willingness to seek help from teachers, family, and friends and maintain community cleanliness can impede epidemic prevention efforts. Epidemic prevention and crisis response mechanisms must be enhanced, and epidemic prevention knowledge, family epidemic prevention, and community cleaning awareness must be reinforced to improve epidemic prevention alertness and the behaviors of families and individuals on the offshore islands to reinforce their current epidemic prevention status.

4. Conclusions and Recommendations With regard to epidemic prevention attitudes, awareness, and behaviors, residents of Northern Taiwan have strong family epidemic prevention habits and consensus; those in Central and Southern Taiwan have favorable life and campus alertness related to epidemic prevention; those in Eastern Taiwan and on the offshore islands are highly cooperative with epidemic prevention efforts. Because all citizens are determined to fight the COVID-19 epidemic, their high levels of cooperativeness and voluntarily mask wearing have contributed to the successful epidemic prevention in Taiwan today. However, overall epidemic prevention measures and information delivery plans have been insufficiently comprehensive. The execution of relevant policies has been insufficient in Northern Taiwan; awareness of individual and community cleaning has been insufficient in Central Taiwan. Few in Southern Taiwan have been willing to report inappropriate epidemic prevention behaviors. Public epidemic prevention facilities are insufficient in Eastern Taiwan. Finally, people’s willingness and methods to solve epidemic-related crises have been insufficient and inappropriate on the offshore islands. All these can inhibit epidemic prevention efforts in Taiwan. Residents are psychologically affected by the COVID-19 crisis; most people report emotional instability, anxiety, headaches, indigestion, and overeating habits; some report experiencing psychological problems such as a sense of loss, weakness, and irritability. Int. J. Environ. Res. Public Health 2020, 17, 4694 20 of 23

Once again, satisfactory family epidemic prevention, personal and public consensus, life and campus alertness, and compliance with public measures and voluntary mask wearing have contributed to the successful epidemic prevention on the offshore islands. However, insufficient family epidemic prevention habits along with people’s lack of epidemic prevention knowledge and willingness to seek help from teachers, family, and friends and maintain community cleanliness can impede epidemic prevention efforts. Epidemic prevention and crisis response mechanisms must be enhanced, and epidemic prevention knowledge, family epidemic prevention, and community cleaning awareness must be reinforced to improve epidemic prevention alertness and the behaviors of families and individuals on the offshore islands to reinforce their current epidemic prevention status.

4. Conclusions and Recommendations With regard to epidemic prevention attitudes, awareness, and behaviors, residents of Northern Taiwan have strong family epidemic prevention habits and consensus; those in Central and Southern Taiwan have favorable life and campus alertness related to epidemic prevention; those in Eastern Taiwan and on the offshore islands are highly cooperative with epidemic prevention efforts. Because all citizens are determined to fight the COVID-19 epidemic, their high levels of cooperativeness and voluntarily mask wearing have contributed to the successful epidemic prevention in Taiwan today. However, overall epidemic prevention measures and information delivery plans have been insufficiently comprehensive. The execution of relevant policies has been insufficient in Northern Taiwan; awareness of individual and community cleaning has been insufficient in Central Taiwan. Few in Southern Taiwan have been willing to report inappropriate epidemic prevention behaviors. Public epidemic prevention facilities are insufficient in Eastern Taiwan. Finally, people’s willingness and methods to solve epidemic-related crises have been insufficient and inappropriate on the offshore islands. All these can inhibit epidemic prevention efforts in Taiwan. Residents are psychologically affected by the COVID-19 crisis; most people report emotional instability, anxiety, headaches, indigestion, and overeating habits; some report experiencing psychological problems such as a sense of loss, weakness, and irritability. Accordingly, we suggest that future research.

(1) Recommendations for Epidemic Prevention Use mass media to convey correct epidemic prevention measures and information. Reinforce personal health habits and encourage people to remind and supervise each other on their habits. Reinforce the execution of administrative decisions in Northern Taiwan. Improve environmental cleanliness in Central Taiwan. Strengthen epidemic prevention consensus in Southern Taiwan. Increase the number of public epidemic prevention facilities in Eastern Taiwan. Last, change the attitudes of offshore island residents in addressing epidemic-related crises. (2) Research Suggestions Further explore awareness, attitudes, and behaviors in relation to epidemic prevention among citizens living in various cities and counties along with their physical and mental health based on spatial factors or numbers of confirmed cases;the effects of demographics and behaviors on epidemic prevention awareness, attitudes, and behaviors and on physical and mental health among individuals; and the effects of various exercising behaviors and health habits on people’s resistance to COVID-19; the effects of the COVID-19 pandemic on various industries.

Author Contributions: H.-H.L. conceived, designed and wrote this paper. C.-H.H. and S.J. helped to check spelling and helped to check grammar of the article, C.-C.W. Help collect sample information. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Acknowledgments: The authors especially thank the editors and anonymous referees for their kindly review and helpful comments. Int. J. Environ. Res. Public Health 2020, 17, 4694 21 of 23

Conﬂicts of Interest: All authors declare no conﬂict of interest.

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