Exploring the Factors Affecting Travel Intention During the COVID-19 Pandemic: A Structural Analysis

Document Type : Research Paper


1 Department of Tourism and Hospitality Management, School of Economics, Management and Social Sciences, Shiraz University

2 Department of Tourism Management, School of Economics, Management and Accounting, Yazd University, Yazd, Iran


The purpose of this study was to identify structural relationships between factors affecting domestic tourism intentions in Iran under COVID-19 conditions, taking into account the importance of behavioral intention in predicting behavior. Therefore, it adds to the emerging body of knowledge about travel intentions during the pandemic. Structural equation modelling was used to analyze 383 online questionnaires, which revealed a positive impact of “frequency of past travel” and a negative effect of “Covid-19 risk knowledge,” “perceived risk,” and “risk aversion attitudes” on “travel intentions.” Furthermore, “perceived risk” and “risk aversion attitudes” mediated the relationship between “frequency of past travel” and “Covid-19 risk knowledge” with “travel intentions.” Meanwhile, “socio-demographic variables” and “travel purposes” moderated the relationships between “risk aversion attitudes” and “travel intentions” and between “perceived risks” and “travel intentions.” The findings enable tourism policy-makers, marketers, and businesses to take purposeful measures to recover domestic tourism.


Main Subjects

Article Title [فارسی]

تحلیل ساختاری عوامل مؤثر بر نیت سفر در دوران پاندمی کوید-19

Authors [فارسی]

  • فاطمه شکاری 1
  • فاطمه عزیزی 2
1 بخش مدیریت گردشگری و هتلداری، دانشکده اقتصاد، مدیریت و علوم اجتماعی، دانشگاه شیراز، شیراز، ایران
2 گروه مدیریت جهانگردی، دانشکده اقتصاد، مدیریت و حسابداری، دانشگاه یزد، یزد ایران
Abstract [فارسی]

بازاریابی اثربخش در شرایط ریسک، مستلزم شناخت نگرش‌ها، ادراکات و نیت سفر گردشگران به منظور بهره‏‌گیری هدفمند از منابع است. هدف از پژوهش حاضر، شناخت روابط ساختاری بین عوامل اثرگذار بر نیت سفر گردشگران داخلی ایران در شرایط پاندمی کوید-19 بوده است. تحلیل داده‏‌های 383 پرسشنامه آنلاین با استفاده از مدل‌سازی معادلات ساختاری، حاکی از تاثیر مثبت فراوانی سفر پیشین و تاثیر منفی دانش از ریسک، ریسک ادراک شده و نگرش نسبت به اجتناب از ریسک بر نیت سفر بود. بعلاوه، ریسک ادراک شده و نگرش نسبت به اجتناب از ریسک در رابطه بین فراوانی سفر پیشین و دانش از ریسک بیماری با نیت سفر نقش میانجی و متغیرهای جمعیت‌شناختی و اهداف سفر در رابطه بین نگرش نسبت به اجتناب از ریسک و ریسک ادراک شده با نیت سفر، نقش تعدیل‏گر ایفا کردند. یافته‌های این تحقیق می‌تواند به سیاست‌گذاران گردشگری، بازاریابان و مشاغل کمک کند تا اقدامات هدفمندی را برای بهبود گردشگری داخلی انجام دهند.

Keywords [فارسی]

  • نیت سفر
  • نگرش نسبت به ریسک
  • ریسک ادراک شده
  • کوید-19
  • ایران
Abdulla Lari, M. A. D., Abdul Hamid, N., & Abdulla Lari, D. A. D. (2020). Development of structural mediation model of innovative strategy, employees’ job performance and technology for UAE government sector. International Journal of Sustainable Construction Engineering and Technology, 11(2), 188-195. https://publisher.uthm.edu.my/ojs/index.php/IJSCET/article/view/7399
Abdullah, M., Dias, C., Muley, D., & Shahin, M. (2020). Exploring the impacts of COVID-19 on travel behavior and mode preferences. Transportation Research Interdisciplinary Perspectives, 8, 100255. https://doi.org/https://doi.org/10.1016/j.trip.2020.100255
Adeloye, D., Carr, N., & Insch, A. (2020). Domestic tourists’ types of exposure to terrorism and travel intentions. Current Issues in Tourism, 24(17),  2489-2500. https://doi.org/https://doi.org/10.1080/13683500.2020.1844161
Backer, E., & Ritchie, B. W. (2017). VFR travel: A viable market for tourism crisis and disaster recovery? International Journal of Tourism Research, 19(4), 400-411. https://doi.org/https://doi.org/10.1002/jtr.2102
Bae, S. Y., & Chang, P.-J. (2021). The effect of coronavirus disease-19 (COVID-19) risk perception on behavioural intention towards ‘untact’ tourism in South Korea during the first wave of the pandemic (March 2020). Current Issues in Tourism, 24(7), 1017-1035. https://doi.org/10.1080/13683500.2020.1798895
Banerjee, S. (2020). Factors impacting state branding communication success: A mediating and multigroup analysis. Place Branding and Public Diplomacy, 17(4), 317–335.  https://doi.org/10.1057/s41254-020-00175-2
Baron, R., & Kenny, D. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182. https://doi.org/10.1037//0022-3514.51.6.1173
Bayih, B. E., & Singh, A. (2020). Modeling domestic tourism: Motivations, satisfaction and tourist behavioral intentions. Heliyon, 6(9), e04839. https://doi.org/https://doi.org/10.1016/j.heliyon.2020.e04839
Chua, B.-L., Al-Ansi, A., Lee, M. J., & Han, H. (2021). Impact of health risk perception on avoidance of international travel in the wake of a pandemic. Current Issues in Tourism, 24(7), 985-1002. https://doi.org/10.1080/13683500.2020.1829570
Correia, A., Pimpao, A., & Crouch, G. (2008). Perceived risk and novelty-seeking behavior: The case of tourists on low-cost travel in Algarve (Portugal). In A. G. Woodside (Ed.), Advances in culture, tourism and hospitality research (pp. 1-26). Emerald Group Publishing Limited. https://doi.org/https://doi.org/10.1016/S1871-3173(08)02001-6
Croson, R., & Gneezy, U. (2009). Gender differences in preferences. Journal of Economic Literature, American Economic Association, 47(2), 448-474.
Das, S. S., & Tiwari, A. K. (2020). Understanding international and domestic travel intention of Indian travellers during COVID-19 using a Bayesian approach. Tourism Recreation Research, 46(2), 1-17. https://doi.org/10.1080/02508281.2020.1830341
Ertz, M., Karakas, F., & Sarigollu, E. (2016). Exploring pro-environmental behaviors of consumers: An analysis of contextual factors, attitude, and behaviors. Journal of Business Research, 60, 3971-3980. https://doi.org/10.1016/j.jbusres.2016.06.010
Essmui, H., Berma, M., Shahadan, F., Ramlee, S., & Mohd, M. (2014). Structural equation model for analyzing the impact of business environment on firm’s growth. International Journal of Economics and Finance, 6(9), 177-189. https://doi.org/10.5539/ijef.v6n9p177
EuropeanCommission. (2020). COVID-19, future pandemics and other crises in the global context.https://ec.europa.eu/info/research-and-innovation/strategy/support-policy-making/scientific-support-eu-policies/group-chief-scientific-advisors/covid-19-future-pandemics-and-other-crises-global-context_en
Floyd, M. F., Gibson, H., Pennington-Gray, L., & Thapa, B. (2004). The effect of risk perceptions on intentions to travel in the aftermath of September 11, 2001. Journal of Travel & Tourism Marketing, 15(2-3), 19-38. https://doi.org/10.1300/J073v15n02_02
Fornell, C., & Larcker, D. F. (1981). Evaluating structural equation models with unobservable variables and measurement error. Journal of Marketing Research, 18(1), 39-50. https://doi.org/10.2307/3151312
Fricker, R. (2008). Sampling methods for web and e-mail surveys. In N. Fielding, R, M.  Lee, & G. Blank (Eds.), The SAGE handbook of online research methods (pp. 195-216). SAGE Publications, Ltd. https://doi.org/https://www.doi.org/10.4135/9780857020055
Fuchs, G., & Reichel, A. (2006). Tourist destination risk perception: The case of Israel. Journal of Hospitality & Leisure Marketing, 14(2), 83-108. https://doi.org/10.1300/J150v14n02_06
Ghorbanzadeh, D., & Aghamohammadi, J. (2021). Investigating the effect of perception of risk of Covid-19 on tourists’ behavioral intention towards untact tourism Case study: Visitors to the tourist attractions of Amol city in the second wave of outbreak. Urban Tourism, 8(1), 15-31. https://doi.org/10.22059/jut.2021.313395.854
Godovykh, M., Pizam, A., & Bahja, F. (2021). Antecedents and outcomes of health risk perceptions in tourism, following the COVID-19 pandemic. Tourism Review, 76(4), 737-748. https://doi.org/10.1108/TR-06-2020-0257
Gössling, S., Scott, D., & Hall, C. M. (2021). Pandemics, tourism and global change: A rapid assessment of COVID-19. Journal of Sustainable Tourism, 29(1), 1-20. https://doi.org/10.1080/09669582.2020.1758708
Hair, J. F., Black, W. C., Babin, B. J., Anderson, R. E., & Tatham, R. L. (2006). Multivariate data analysis (Vol. 6). Prentice-Hall.
Han, H., Al-Ansi, A., Chua, B.-L., Tariq, B., Radic, A., & Park, S.-H. (2020). The post-coronavirus world in the international tourism industry: Application of the theory of planned behavior to safer destination choices in the case of US outbound tourism. International journal of environmental research and public health, 17(18),  . https://doi.org/10.3390/ijerph17186485
Hassan, S. B., & Soliman, M. (2021). COVID-19 and repeat visitation: Assessing the role of destination social responsibility, destination reputation, holidaymakers’ trust and fear arousal. Journal of Destination Marketing and Management, 19, 100495. https://doi.org/10.1016/j.jdmm.2020.100495
He, L., Park, K., & Roehl, W. S. (2013). Religion and perceived travel risks. Journal of Travel & Tourism Marketing, 30(8), 839-857. https://doi.org/10.1080/10548408.2013.835674
Hotle, S., Murray-Tuite, P., & Singh, K. (2020). Influenza risk perception and travel-related health protection behavior in the US: Insights for the aftermath of the COVID-19 outbreak. Transportation Research Interdisciplinary Perspectives, 5, 100127. https://doi.org/https://doi.org/10.1016/j.trip.2020.100127
Hsiao, C.-H., & Yang, C. (2010). Predicting the travel intention to take High Speed Rail among college students. Transportation Research Part F: Traffic Psychology and Behaviour, 13(4), 277-287. https://doi.org/https://doi.org/10.1016/j.trf.2010.04.011
Hu, L.-T., & Bentler, P. M. (1995). Evaluating model fit. In R. H. Hoyle (Ed.), Structural equation modeling: Concepts, issues, and applications. Sage Publications.
IRNA. (2021). www.irna.ir/news/84448823/
Ivanova, M., Ivanov, I. K., & Ivanov, S. (2021). Travel behaviour after the pandemic: The case of Bulgaria. Anatolia, 32(1), 1-11. https://doi.org/10.1080/13032917.2020.1818267
JamalKhan, M., Chelliah, S., & Ahmed, S. (2017). Factors influencing destination image and visit intention among young women travellers: Role of travel motivation, perceived risks, and travel constraints. Asia Pacific Journal of Tourism Research, 22(11), 1139-1155. https://doi.org/10.1080/10941665.2017.1374985
Jang, S., Bai, B., Hu, C., & Wu, C.-M. E. (2009). Affect, travel motivation, and travel intention: A senior market. Journal of Hospitality & Tourism Research, 33(1), 51-73. https://doi.org/10.1177/1096348008329666
Karl, M. (2016). Risk and uncertainty in travel decision-making: Tourist and destination perspective. Journal of Travel Research, 57(1), 129-146. https://doi.org/10.1177/0047287516678337
Karl, M., Muskat, B., & Ritchie, B. (2020). Which travel risks are more salient for destination choice? An examination of the tourist’s decision-making process. Journal of Destination Marketing and Management, 18, 1-11. https://doi.org/10.1016/j.jdmm.2020.100487
Karl, M., & Schmude, J. (2017). Understanding the role of risk (perception) in destination choice: A literature review and synthesis. Tourism: An International Interdisciplinary Journal, 65(2), 138-155. https://hrcak.srce.hr/183753
Khan, M. J., Chelliah, S., & Ahmed, S. (2018). Intention to visit India among potential travellers: Role of travel motivation, perceived travel risks, and travel constraints. Tourism and Hospitality Research, 19(3), 351-367. https://doi.org/10.1177/1467358417751025
Khan, M. J., Chelliah, S., Khan, F., & Amin, S. J. T. R. (2019). Perceived risks, travel constraints and visit intention of young women travelers: The moderating role of travel motivation. Tourism Review, 74(3), 721-738. https://doi.org/10.1108/TR-08-2018-0116
Kline, R. B. (2005). Principles and practice of structural equation modeling (2nd ed.) Guilford Publications. https://books.google.com/books?id=EkMVZUxZrgIC
Kline, R. B. (2011). Principles and practice of structural equation modeling (3rd ed.). The Guilford Press. https://books.google.com/books?id=EkMVZUxZrgIC
Koo, C., Joun, Y., Han, H., & Chung, N. (2016). A structural model for destination travel intention as a media exposure: Belief-desire-intention model perspective. International Journal of Contemporary Hospitality Management, 28, 1338-1360. https://doi.org/10.1108/IJCHM-07-2014-0354
Lam, T., & Hsu, C. H. C. (2006). Predicting behavioral intention of choosing a travel destination. Tourism Management, 27(4), 589-599. https://doi.org/https://doi.org/10.1016/j.tourman.2005.02.003
Laver, S. M., Wetzels, J., & Behrens, R. H. (2006). Knowledge of Malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travelers exiting Zimbabwe from Harare and Victoria Falls International Airport. Journal of Travel Medicine, 8(6), 298-303. https://doi.org/10.2310/7060.2001.23975
Lee, C.-K., Song, H.-J., Bendle, L. J., Kim, M.-J., & Han, H. (2012). The impact of non-pharmaceutical interventions for 2009 H1N1 influenza on travel intentions: A model of goal-directed behavior. Tourism Management, 33(1), 89-99. https://doi.org/10.1016/j.tourman.2011.02.006
Lepp, A., & Gibson, H. (2003). Tourist roles, perceived risk and international tourism. Annals of Tourism Research, 30(3), 606-624. https://doi.org/https://doi.org/10.1016/S0160-7383(03)00024-0
Lepp, A., & Gibson, H. (2008). Sensation seeking and tourism: Tourist role, perception of risk and destination choice. Tourism Management, 29(4), 740-750. https://doi.org/https://doi.org/10.1016/j.tourman.2007.08.002
Li, H., Meng, F., & Zhang, Z. (2016a). Non-participation of domestic tourism: Analyzing the influence of discouraging factors. International Journal of Tourism Research, 18(6), 567-578. https://doi.org/https://doi.org/10.1002/jtr.2074
Li, J., Pearce, P. L., Morrison, A. M., & Wu, B. (2016b). Up in smoke? The impact of smog on risk perception and satisfaction of international tourists in Beijing. International Journal of Tourism Research, 18(4), 373-386. https://doi.org/https://doi.org/10.1002/jtr.2055
Luo, J. M., & Lam, C. F. (2020). Travel anxiety, risk attitude and travel intentions towards “travel bubble” destinations in Hong Kong: Effect of the fear of COVID-19. International Journal of Environmental Research, 17(21),  . https://doi.org/https://doi.org/10.3390/ijerph17217859
Mandrik, C., & Bao, Y. (2005). Exploring the concept and measurement of general risk aversion. Advances in Consumer Research, 32, 531-539.
Matiza, T., & Kruger, M. (2021). Ceding to their fears: A taxonomic analysis of the heterogeneity in COVID-19 associated perceived risk and intended travel behaviour. Tourism Recreation Research, 46(2), 158-174.         https://doi.org/https://doi.org/10.1080/02508281.2021.1889793
Nazneen, S., Hong, X., & Ud din, N. (2020). COVID-19 crises and tourist travel risk perceptions. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3592321
Neuburger, L., & Egger, R. (2021). Travel risk perception and travel behaviour during the COVID-19 pandemic 2020: A case study of the DACH region. Current Issues in Tourism, 24(7), 1003-1016. https://doi.org/10.1080/13683500.2020.1803807
Nugraha, A., Hamin, H., & Elliott, G. (2016). Tourism destination decisions: The impact of risk aversion and prior experience. Asia Pacific Journal of Tourism Research, 21(12), 1274-1284. https://doi.org/10.1080/10941665.2016.1141225
OECD. (2020a). Mitigating the impact of COVID-19 on tourism and supporting recovery  https://doi.org/doi:https://doi.org/10.1787/47045bae-en
OECD. (2020b). Tourism Policy Responses to the coronavirus (COVID-19). https://www.oecd.org
Peluso, A. M., & Pichierri, M. (2020). Effects of socio-demographics, sense of control, and uncertainty avoidability on post-COVID-19 vacation intention. Current Issues in Tourism, 24(19),  2755-2767. https://doi.org/10.1080/13683500.2020.1849050
Qi, C. X., Gibson, H. J., & Zhang, J. J. (2009). Perceptions of risk and travel intentions: The case of China and the Beijing Olympic Games. Journal of Sport & Tourism, 14(1), 43-67. https://doi.org/10.1080/14775080902847439
Quintal, V., Sung, B., & Lee, S. (2021). Is the coast clear? Trust, risk-reducing behaviours and anxiety toward cruise travel in the wake of COVID-19. Current Issues in Tourism, 25(2), 206-218. https://doi.org/https://doi.org/10.1080/13683500.2021.1880377
Quintal, V. A., Lee, J. A., & Soutar, G. N. (2010). Risk, uncertainty and the theory of planned behavior: A tourism example. Tourism Management, 31(6), 797-805. https://doi.org/https://doi.org/10.1016/j.tourman.2009.08.006
Rasoolimanesh, S. M., Seyfi, S., Rastegar, R., & Hall, C. M. (2021). Destination image during the COVID-19 pandemic and future travel behavior: The moderating role of past experience. Journal of Destination Marketing and Management, 21, 100620. https://doi.org/https://doi.org/10.1016/j.jdmm.2021.100620
Rastegar, R., Seyfi, S., & Rasoolimanesh, S. M. (2021). How COVID-19 case fatality rates have shaped perceptions and travel intention? Journal of Hospitality and Tourism Management, 47, 353-364. https://doi.org/10.1016/j.jhtm.2021.04.006
Reichel, A., Fuchs, G., & Uriely, N. (2007). Perceived risk and the non-institutionalized tourist role: The case of Israeli student ex-backpackers. Journal of Travel Research, 46(2), 217-226. https://doi.org/10.1177/0047287507299580
Sánchez-Cañizares, S. M., Cabeza-Ramírez, L. J., Muñoz-Fernández, G., & Fuentes-García, F. J. (2021). Impact of the perceived risk from Covid-19 on intention to travel. Current Issues in Tourism, 24(7), 970-984. https://doi.org/10.1080/13683500.2020.1829571
Sharifi, H., Karamouzian, M., Khorrami, Z., Khalili, M., Mostafavi, E., Eybpoosh, S., Mirzazadeh, A., Haghdoost, A. (2020). The accuracy of modeling the burden of COVID-19 in Iran with international airline travelers’ data. Annals of internal medicine, 173(1), 74-75.  
Sharifpour, M., Walters, G., & Ritchie, B. W. (2014). Risk perception, prior knowledge, and willingness to travel: Investigating the Australian tourist market’s risk perceptions towards the Middle East. Journal of Vacation Marketing, 20(2), 111-123. https://doi.org/10.1177/1356766713502486
Sharifpour, M., Walters, G., Ritchie, B. W., & Winter, C. (2013). Investigating the role of prior knowledge in tourist decision making: A structural equation model of risk perceptions and information search. Journal of Travel Research, 53(3), 307-322. https://doi.org/10.1177/0047287513500390
Sönmez, S., & Graefe, A. (1998). Determining future travel behavior from past travel experience and perceptions of risk and safety. Journal of Travel Research - J TRAVEL RES, 37, 171-177. https://doi.org/10.1177/004728759803700209
TEHRANTIMES. (18 September  2020). ‘Smart, responsible traveling’ should replace ‘do not travel’ recommendations. https://www.tehrantimes.com/news/452602/Smart-responsible-traveling-should-replace-do-not-travel
Turnšek, M., Brumen, B., Rangus, M., Gorenak, M., Mekinc, J., & Štuhec, T. L. (2020). Perceived threat of COVID-19 and future travel avoidance: Results from an early convenient sample in Slovenia. Academica Turistica-Tourism and Innovation Journal, 13(1), 3-19.
UNWTO. (2020a). Supporting jobs and economies through Travel & Tourism – A call for action to mitigate the socio-economic impact of COVID-19 and accelerate recovery. https://www.e-unwto.org/doi/book/10.18111/9789284421633
UNWTO. (2020b). UNWTO global guidelines to restart tourism. https://webunwto.s3.eu-west-1.amazonaws.com/s3fs-public/2020-05/UNWTO-Global-Guidelines-to-Restart-Tourism.pdf
UNWTO. (2020c). UNWTO priorities for tourism recovery: Global guidelines. https://webunwto.s3.eu-west-1.amazonaws.com/s3fs-public/2020-05/UNWTO-Priorities-for-Global-Tourism-Recovery.pdf
UNWTO. (2020d). UNWTO tourism highlights: 2020 Edition. https://www.e-unwto.org/doi/book/10.18111/9789284422456
UNWTO. (2021a). International tourism and COVID-19. https://www.unwto.org/international-tourism-and-covid-19
UNWTO. (2021b). Yearbook  of tourism statistics data 2015 – 2019. https://www.e-unwto.org/doi/book/10.18111/9789284422487
Wang, Y., Han, Q., De Vries, B., & Zuo, J. (2016). How the public reacts to social impacts in construction projects? A structural equation modeling study [Aufsatz in Zeitschrift, Article in journal]. International Journal of Project Management, 34(8), 1433-1448. https://doi.org/10.1016/j.ijproman.2016.07.008 [DOI]
WHO. (2021). Iran (Islamic Republic of): WHO coronavirus disease (COVID-19) dashboard. https://covid19.who.int/region/emro/country/ir
Williams, A. M., & Baláž, V. (2013). Tourism, risk tolerance and competences: Travel organization and tourism hazards. Tourism Management, 35, 209-221. https://doi.org/https://doi.org/10.1016/j.tourman.2012.07.006
WTTC. (2021). Iran 2021 Annual research: Key highlights. https://wttc.org/Research/Economic-Impact
Xu, P., & Cheng, J. (2021). Individual differences in social distancing and mask-wearing in the pandemic of COVID-19: The role of need for cognition, self-control and risk attitude. Personality and Individual Differences, 175, 110706. https://doi.org/10.1016/j.paid.2021.110706
Yang, E. C. L., Khoo-Lattimore, C., & Arcodia, C. (2017). A systematic literature review of risk and gender research in tourism. Tourism Management, 58, 89-100. https://doi.org/https://doi.org/10.1016/j.tourman.2016.10.011
Yang, E. C. L., Sharif, S. P., & Khoo-Lattimore, C. (2015). Tourists’ risk perception of risky destinations: The case of Sabah’s eastern coast. Tourism and Hospitality Research, 15(3), 206-221. https://doi.org/10.1177/1467358415576085
Yavari, F., & Mansourimoayyed, F. (2021). Analysis the role of advertising on behavioral intentions in tourism industry in post-corona era Tourism Studies, 15(51), 33-58. https://doi.org/10.22054/tms.2020.52951.2335
Zhan, L., Zeng, X., Morrison, A. M., Liang, H., & Coca-Stefaniak, J. A. J. C. I. i. T. (2020). A risk perception scale for travel to a crisis epicentre: Visiting Wuhan after COVID-19. Current Issues in Tourism, 25(1), 150-167. https://doi.org/https://doi.org/10.1080/13683500.2020.1857712
Zhang, L., Jiang, H., & Jin, T. (2020). Leader-member exchange and organisational citizenship behaviour: The mediating and moderating effects of role ambiguity. Journal of Psychology in Africa, 30(1), 17-22. https://doi.org/10.1080/14330237.2020.1721948
Zhu, H., & Deng, F. (2020). How to influence rural tourism intention by risk knowledge during COVID-19 containment in China: Mediating role of risk perception and attitude. International Journal of Environmental Research and Public Health, 17(10),  . https://doi.org/https://doi.org/10.3390/ijerph17103514