Development and cross-national validation of the PEPB: a pandemic and emergency preparedness and behaviours monitor in four European countries

Background The COVID-19 pandemic highlighted the critical role of population behaviour in controlling the devastating impact of a health emergency. The absence of a standardised, cross-national survey that monitors preparedness behaviours and their determinants limit timely, evidence-informed public health preparedness and policy development. This study introduces and validates the Pandemic and Emergency Preparedness Behaviour (PEPB) monitor, a theory-informed survey designed to assess behavioural preparedness for future pandemics and emergencies.Methods Data were collected in March 2024 among adults aged ≥18 years in four European countries (the Netherlands, Spain, Ireland, and Slovenia; total N = 4,636). The PEPB monitor includes validated and new constructs covering preparedness and health behaviours, psychosocial determinants, preparedness perceptions, and self-reported health, theoretically supported by the COM-B model. Psychometric properties were examined using multigroup structural equation modelling, including tests of validity, internal reliability, and cross-national measurement invariance. Cross-national comparisons of preparedness-related behaviours and determinants were conducted, and illustrative regression analyses were performed to demonstrate policy-relevant use cases.Results Most multi-item constructs demonstrated good internal reliability and adequate structural validity across countries. Metric invariance was supported for all scales, indicating that associations between constructs can be meaningfully compared cross-nationally. Scalar invariance was supported for all constructs, except for mental health, perceived likelihood of disaster occurrence, and perceived severity of disaster consequences. Substantial cross-national differences were observed in hygiene behaviours, household preparedness, institutional trust, health literacy, and conspiracy beliefs. Regression analyses illustrate how the PEPB monitor can be used to identify behavioural, social, and institutional determinants of key preparedness-relevant outcomes.Conclusions By testing the survey’s psychometric properties in diverse national settings, the PEPB monitor provides an empirical baseline reference for observing societal behavioural changes during future pandemic and health emergency threats. Substantial cross-national variation in preparedness-related behaviours and institutional trust indicates that behavioural readiness during non-crisis phases cannot be assumed. Continued implementation of the PEPB monitor over time across countries can support evidence-informed preparedness policy and strengthen societal resilience to future public health emergencies.