5.1. Role of WASH and health facility and knowledge in urban marginalized people's threat and coping appraisal
Although WASH has a vital role in combating COVID-19 in the developing world (Ezbakhe et al., 2019, UN,2020; UNICEF, 2020), the findings of this study showed that urban marginalized people have inequalities access to clean water, poor sanitation, shortages of personal protective equipment and public healthcare services. The situation of urban marginalized people in Thailand is similar to many developing countries such as Kenya, Africa, Pakistan, India, where poor people and low-skilled worker migrants struggle to access healthcare services and unaffordable protective equipment (Zulu et al., 2011; UNESCO, 2020).
The findings revealed that the marginalized urban people tended to have basic knowledge of COVID-19, WASH practices, and a high perception of threat and coping appraisal and protective intention. People who can access WASH and health care tended to have higher protection intention against COVID-19, and as a result, perceive the pandemic more severe than people having no access to WASH and healthcare. Most Thai respondents tended to have better access these public services and have higher education (nearly 50% of respondents had tertiary education) than non-Thai migrant groups. The barriers to WASH and healthcare services are due to unemployment, hidden social status, expensive health insurance, low health literacy, language barrier, and social stigma decrease the protective motivation awareness of marginalized people (Essendi et al., 2011; George et al.,2018) which may constraint their protection intentions toward Covid-19.
5.3 Predicting protective motivation behaviours towards health infection.
This study developed a conceptual framework based on Protective Motivation Theory (PMT) and Knowledge, Attitude, and Practice (KAP) to predict WASH protective behaviours intention against COVID-19. PMT is a social cognitive process with information, knowledge, and attitude (Milne et al., 2000), and many researchers widely used PMT in predicting 'intention' behaviours. Therefore, it can be an alternative theory for KAP to investigate people's knowledge and experiences relevant health behaviours (Xiao et al., 2014), and PMT components should be considered in KAP because it provides a strong predictor and fills the gap of the prediction results (Nabizadeh et al., 2014).
In this study, a part of PMT plays a role in the 'attitude' component in the KAP model, including perceived severity, self-efficacy, and response efficacy. The combination of PMT and KAP helps researchers to understand knowledge significantly affects current practices and vulnerability due to knowledge linked to people's awareness, motivation, and competence to understand, appraise, assess health risk or vulnerability situations leading people to judge and form accurate decisions by maintaining or improving their health practices regarding disease prevention and health protection (He et al., 2016). The model results showed that knowledge was a vital factor that had a greater influence on practice (Allan et al. 2013) and behaviour intention through threat appraisal and coping appraisal (Rogers,1983; Renner et al. 2008). It also can shape people's risk perception, which helps to decrease people's perceived severity and vulnerability beliefs (Eppright et al., 1994). Vulnerability can help to predict intentional behaviours as it is significantly associated with people's knowledge and emotions. These emotions such as fear, anxiety are roots of people's survival favouring the prediction of health preventive behaviours (Stangier et al., 2021).
The results also showed that current practices could influence the perception of coping appraisal and threat appraisal. If people have good current practices, it can reduce or prevent the severity of harmful events and increase the perception of self-efficacy and response efficacy regarding disease prevention benefits. Poor health practices or negative bias on health practices can undermine protective behavioural intention (Nguyen et al., 2019a; Park et al., 2020). Current practices can influence people's health behavioural intention (Fishbein et al., 2001; Chamroonsawasdi et al., 2017).
The model also confirmed that perceived severity, self-efficacy, response efficacy are all three variables influencing protective motivation behaviours. People with high awareness of health and disease severity will have high motivation to adopt protective behaviours (Tazval et al.,2016; Ezati et al., 2021). Whereas perceived self-efficacy is the strongest factor among PMT constructs, many studies found (e.g., Hernandez-Padilla et al., 2020; Janmaimool, 2020). People with high efficacy tend to cope with the disease, leading them to have higher preventive motivation (Leigh et al., 2020). Furthermore, perceived response efficacy is found as a variable supporting self-efficacy (Rippetoe et al.,1987; Milne et al., 2000; Leigh et al., 2020). Response efficacy can enhance self-efficacy on self-protection. Protective motivation behaviours have resulted from threat appraisal and coping appraisal (Fishbein et al., 2001; Tang and Feng, 2018). Thus, the model results revealed that the field data in this case study fits well the conceptual model by combining KAP and PMT to predict urban marginalized people's protective motivation behaviours towards Covid-19.