research about covid 19 tagalog

ORIGINAL RESEARCH article

The importance of well-being on resiliency of filipino adults during the covid-19 enhanced community quarantine: a necessary condition analysis.

• 1 College of Arts and Sciences, Manila Tytana Colleges, Pasay, Philippines
• 2 Psycli-Nik Psychological Assessment and Intervention Services, Zamboanga City, Philippines

Nation-wide community quarantines and social distancing are part of the new normal because of the global COVID-19 pandemic. Since extensive and prolonged lockdowns are relatively novel experiences, not much is known about the well-being of individuals in such extreme situations. This research effort investigated the relationship between well-being elements and resiliency of 533 Filipino adults who were placed under the nationwide enhanced community quarantine (ECQ) during the COVID-19 pandemic. Participants comprised of 376 females (70.56%) and 157 males (29.45%). The median and mode ages of the participants is 23 years, while 25 is the mean age. PERMA Profiler was used to measure participants’ well-being elements, while Connor-Davidson Resiliency Scale-10 (CD-RISC-10) was used to measure their resiliency. Collected data were analyzed using the regression model and necessary condition analysis. This study corroborated that all the five pillars of well-being are significant positive correlates of resiliency ( p < 0.00) in quarantined adults. The results shown accomplishment ( β = 0.447, p < 0.01) positively predicts resiliency, while negative emotions ( β = −0.171, p < 0.00) negatively predict resiliency. Lastly, the five pillars of well-being are necessary-but-not-sufficient conditions (ceiling envelopment with free disposal hull, CE-FDH p < 0.00) of resiliency. Our results cast a new light on well-being elements as constraints rather than enablers of resiliency. This novel result shows that optimum resiliency is only possible when all the five pillars of well-being are taken care of and when a person is at least minimally contented with their physical health. The present findings underscore the importance of a holistic as against an atomistic approach to maintaining good mental health, which suggests that deficiencies in certain areas of well-being may not be fully addressed by overcompensating on other areas, as all five pillars of well-being are necessary-but-not-sufficient conditions of resiliency. The study ends with the recommendation for the use of necessary condition analysis to study both classical and novel psychological research problems.

The Importance of Well-Being on Resiliency of Filipino Adults During the COVID-19 Who are Community Quarantined

The infectious Coronavirus disease (COVID-19), which causes respiratory illness includes flu-like symptoms such as cough, fever, and in more severe cases, breathing difficulties. COVID-19 is mainly spread through contact with an infected person who sneezes or coughs. It can be acquired when a person touches their eyes, nose, or mouth after touching objects or surfaces that have the virus on it ( World Health Organization, 2020 ). Starting December 2019, countries imposed travel bans and asked individuals who have possibly been exposed to the contagion to isolate themselves in a dedicated quarantine facility or at home ( Brooks et al., 2020 ) at an unprecedented scale. The Philippines reported its first case of COVID-19 on January 30, 2020. Since then, the number of reported cases exponentially increased by the day ( ABS-CBN Investigative and Research Group, 2020 ). As of December 12, 2020, 447,039 infected cases were reported throughout the country. Of the total number of cases, 409,329 have recovered, and 8,709 have died ( Department of Health, 2020 ).

As a response to the growing threat of the pandemic, the entire Luzon was placed under enhanced community quarantine (ECQ; Medialdea, 2020 ). Shortly, both Visayas and Mindanao followed suit. The said measure involves draconian restrictions: that include the establishment of checkpoints in most cities; the suspension of classes in all levels; the prohibition of mass gatherings; the temporary shutting down of non-essential businesses; the banning of public utilized utility vehicles; and the strict implementation of home isolation. Although it was initially planned to end on April 12, 2020 ( Abueg, 2020 ), several subsequent recommendations both from the national and local governments extended the nationwide community quarantine until December 31, 2020 ( CNN Philippines Staff, 2020 ). As the nation’s Gross Domestic Product (GDP) shrank 16.5% in the second quarter of 2020, the Philippines officially entered recession as an effect of the extended quarantines ( Agence France-Presse, 2020 ). While quarantine is often among the initial responses against an emerging infectious disease ( Parmet and Sinha, 2020 ), it is often unpleasant for those who are required to submit to it and may lead to several harmful conditions for some persons ( Hawryluck et al., 2004 ; Brooks et al., 2020 ). Hence, the psychological effects of quarantine have received considerable attention. Barbisch et al. (2015) reported that losing autonomy, isolation away from loved ones, uncertainty, and boredom could lead to adverse effects on an individual’s well-being. Following the imposition of cordon sanitaire in previous outbreaks, substantial anger, anxiety and even an increase in suicide rates have been reported ( Brooks et al., 2020 ). Similarly, the National Center for Mental Health (NCMH) in the Philippines reported that depression and other mental health issues were on the rise after imposing ECQ in different provinces in the country ( Tenorio, 2020 ).

Well-Being and Its Elements

It is important to note that while quarantines are often unpleasant, their effect on people diverge. While there are individuals who experience mental health issues, there are also those who are more resilient and can move on with their lives. This highlights the importance of studying not only how individuals suffer in light of community quarantines, but also how they cope, and even flourish in the face of such challenging times. Seligman (2011) argued that even in difficult situations, human beings are motivated to thrive and not just merely survive. According to Fredrickson and Losada (2005) , flourishing means living “within an optimal range of human functioning, one that connotes goodness, generativity, growth, and resilience.” Based on this definition, resilience appears to arise from flourishing. Well-being predicts resiliency. For clarity, the terms “flourishing,” “thriving,” and “well-being” are used interchangeably in the literature ( Butler and Kern, 2016 ). Therefore, we also use the terms interchangeably here.

Well-being Theory of Seligman (2011) advocates that flourishing arises from five well-being pillars-Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment, hence PERMA. It is important to note that no single element defines well-being, but each contributes to it. Positive emotions include an extensive variety of feelings, which include excitement, satisfaction, pride, and awe. Previous reviews highlight the important role of these emotions in positive life outcomes ( Butler and Kern, 2016 ). Engagement involves activities that stimulate and develop upon an individual’s interests. Csikszentmihalyi (2009) argues that true engagement leads to a state of deep and effortless involvement where an individual is completely absorbed in an activity that often leads to a sense of joy and lucidity. Relationships are social connections important in stimulating positive emotions. They can either be work-related, familial, romantic, and even platonic. The experiences that contribute to well-being are often amplified through our relationships. Positive relationships have been linked to positive outcomes such as better physical health, healthier behaviors, less psychopathology, and lower mortality risk ( Tay et al., 2013 ). A sense of meaning is derived from having a direction in life, belonging to a cause larger than the self, and serving a purpose greater than one’s immediate needs ( Steger, 2012 ). Such activities provide a sense that life is valuable and worthwhile. Various societal institutions such as religion, politics, justice, and community social causes enable a sense of meaning. Accomplishments are pursuits toward and reaching goals, mastery, and efficacy to complete tasks ( Butler and Kern, 2016 ) in various domains such as the workplace, in sports and games, and even in hobbies and interests. Seligman (2011) argued that people pursue accomplishments even when they do not result in positive emotions, meaning, or relationships. Although PERMA was developed mainly within the Western context, several researches found that PERMA is experienced in culturally consistent manners in non-Western societies such as the United Arab Emirates ( Lambert and Pasha-Zaidi, 2016 ), Hong-Kong ( Lai et al., 2018 ), and the Philippines ( Nebrida and Dullas, 2018 ).

Defining Resilience

Over the past decade, resilience has become a popular concept in both research and clinical practice ( Kumpfer, 2002 ; Walsh-Dilley and Wolford, 2015 ). Despite the lack of consensus in how it is defined ( Vella and Pai, 2019 ), it is accepted that resilience involves the positive adaptation following a stressful or adverse experience ( Porterfield et al., 2010 ). Most definitions acknowledge two key points about resilience ( Herrman et al., 2011 ). First, is that various factors interact with it. For example, personal characteristics such as personality traits ( Oshio et al., 2018 ), self-esteem ( Karatas and Cakar, 2011 ), and even age ( Diehl and Hay, 2010 ) influence resilience. Social and community factors ( Harms et al., 2018 ) such as secure attachments, the presence of a role model ( Levine, 2003 ), family stability ( Grubman, 2018 ), and culture ( Ungar, 2008 ) affect the ability to cope with daily struggles. Second, resilience is time and context-specific and may not be present across all life domains. Resilience appears to be receptive to the influence of specific situations ( Hayman et al., 2017 ) such as unique stressors ( Jex et al., 2013 ) like war and other happenstances ( Besser et al., 2014 ).

While the aforementioned literature provides key insights into the definition, factors, and contexts of resilience, most research focuses on factors are outside the control of the individual. While these researches are important in explaining the development of resilience, they lack emphasis on positive mechanisms, which are behaviors a person can perform to facilitate resilience. While resilience has been studied both in daily and unique stressors, none focused on the novel situation of wide range community quarantines. Therefore, despite the abundance of resilience-related research, the question remains “What positive mechanisms are involved in the resilience of people who are subjected to quarantine?”

The Present Study

In this paper, we introduced a novel approach in understanding the necessary but not sufficient nature of the aforementioned positive aspects of well-being in predicting resiliency. We used Dul (2016) Necessary Condition Analysis (NCA), which seeks to identify necessary-but-not-sufficient conditions in data sets ( Dul, 2018 ). A necessary condition is a crucial factor in an outcome. If it is not in place, the outcome will not be achieved, but its sole presence does not guarantee that the outcome will be obtained. Without the necessary condition, however, there is a certain failure, which may not be compensated by other determinants of the outcome. Necessary (but not sufficient) conditions widely exist in real-life. For example, the novel SARS-CoV-2 coronavirus is a necessary-but-not-sufficient condition for COVID-19 ( World Health Organization, 2020 ). Without SARS-CoV-2 coronavirus, an individual will not acquire COVID-19. However, even with SARS-CoV-2 coronavirus, an individual may or may not acquire COVID-19. In the same light, a college student who wants to pass the course, Introduction to Psychology (the outcome) needs to attend 80% of lecture hours (necessary conditions). However, attending class regularly does not guarantee passing the course as other requirements (examinations, seat-works, research work, and journal critique paper) play a role in a student’s grade. Yet, if the student incurs too many absences and tardiness, failure is guaranteed. As seen in the aforementioned examples, necessary causes are not automatically sufficient. They can be seen as constraints, barriers, or obstacles one needs to deal with to arrive at the desired outcome.

While well-being and resiliency are closely related concepts ( Hu et al., 2015 ) Flourishing model of Seligman’s (2011) perceives resiliency as the result of both “surviving” and “thriving” psychological characteristics. This theoretical relationship between well-being and resilience has gained empirical support in recent years ( Harms et al., 2018 ). For example, Martínez-Martí and Ruch (2017) and Burns and Anstey (2010) demonstrated that measures of well-being are not simply redundant with self-report scales of resilience. At the same time, while the relationship between these two concepts are robust, it is rarely straightforward ( Harms et al., 2018 ). Interestingly, some researchers ( Fredrickson et al., 2003 ; Tugade and Fredrickson, 2004 ; Ong et al., 2006 , 2010 ; Kuntz et al., 2016 ) argued that optimal levels of PERMA elements predict resilience in normal sample.

In the light of the foregoing, the present study aims to investigate how PERMA predicts the resiliency of community quarantined individuals. An explanation of possible necessary-but-not-sufficient conditions of resiliency during quarantine may have both theoretical and practical value. Theoretically, an investigation of this sort allows the advancement of our understanding of how a multitude of variables coalesces to produce resiliency in times of quarantine and social isolation. This is significant as wide-range and prolonged quarantines are relatively novel experiences. Hence, not much is known about its psychological implications for human beings. Psychological interventions may target different necessary-but-not-sufficient variables jointly. Because of NCA’s ability to identify bottleneck variables ( Dul, 2019a ), conditions that must be present for resiliency to be possible, interventions may prioritize bottleneck variables of resiliency to maximize the use of limited resources. Lastly, identifying necessary-but-not-sufficient conditions for resiliency may also help individuals who are quarantined to develop their understanding of the behaviors they need to engage to have resiliency. Following this logic, we hypothesize that:

H 01 : PERMA elements predict the resiliency of the community-quarantined individuals.

H 02 : PERMA elements are necessary, but not sufficient conditions, for the resiliency of the community-quarantined individuals.

Methodology

Research design.

To test the assumption that PERMA elements are both sufficient and necessary conditions of resiliency in community quarantined individuals, sufficiency and necessity observational design were used concurrently. In these designs, the conditions (PERMA) and the outcome (resiliency) are observed in real-life context and without the manipulation of the condition. While sufficiency and necessity observational research designs follow the same data gathering procedures, they diverge in data analysis. Dul (2016) argued that NCA is a complement to traditional approaches to analyze relations. As in our research, by using multiple regression we could spot determinants that contribute to resiliency, whereas NCA allowed us to spot critical determinants (constraints) that prevent resiliency from developing. These bottlenecks, when present, prevents resiliency from occurring even when we increase the values of other determinants unless we take away the bottlenecks by increasing the value of the critical determinant. NCA lead us to discover critical determinants that were not part of the determinants identified with the regression model. Using both approaches is critical in adequately understanding the resiliency of individuals who are subjected to the extended ECQ.

Research Participants

Because of the restrictions in both mobility and social interactions as direct consequences of the nationwide ECQ, we used purposive – convenience sampling to recruit Filipino Facebook users who reside in communities placed under the ECQ. The survey was promoted through social media, primarily on Facebook. A total of 541 participants responded to our online survey via Google Form. The minimum age reported was 16 years old, while the maximum age was 64 years old with a median of 23. Because resiliency scores are contingent to age, only those whose ages ranged between emerging adulthood to early middle adulthood (18–40) were included in the study.

Inclusion Criteria

Participants that were considered to partake in the research met the following criteria: first, a participant must be aged 18 to 40 years old. Second, he/she resides in a quarantined area in the Philippines. Third, a participant must be a Filipino citizen as social and cultural factors influence resiliency.

Exclusion Criteria

A participant was excluded in the research because of the following conditions: first, a participant aged less than 18 years old and over 40 years old, a participant who refused to completely answer the online survey questionnaires, and a participant who does not reside in a quarantine area in the Philippines.

Ethical Considerations

In dealing with the participants, respect and protection of the privacy of the participants were prioritized. Thus, privacy and anonymity was of paramount importance. Also, voluntary participation of the chosen participants for said the study was important. Participants had the right to withdraw from the study at any phase of the research if they wished to do so.

Potential participants were fully informed regarding the research, full consent was essential and obtained from the participants. The first page of the online questionnaire required participants to check a box to show consent before having access to the survey. The principle of informed consent involved the researchers providing sufficient information and assurances about taking part to allow potential participants to understand the implications of participation and to reach a fully informed, considered, and freely decided about whether to do so, without the exercise of any pressure or coercion. No incentives were provided in return for their participation.

In collecting data through online surveys, we minimized intrusions on privacy, anonymity, and confidentiality. Before data collection, an adequate level of confidentiality of the research data was ensured to the participants to make them feel secured and protected with the information they shared or contributed. Also, any communication about the research was observed with respect and transparency. Ultimately, research participants are not subjected to harm.

Research Instruments

Google Forms was used to gather sociodemographic variables from the sample and deliver the following self-administered scales, which were used to measure the variables of the current study. Specifically, we used the Connor-Davidson Resiliency Scale-10 (CD-RISC-10) to measure their resiliency, and the PERMA Profiler to measure participants’ well-being elements.

Connor-Davidson Resiliency Scale

The CD-RISC-10 is a 10 item scale that is used to measure resiliency, operationally defined as the ability to “thrive in the face of adversity” ( Connor and Davidson, 2003 ). The unidimensional CD-RISC-10 evaluates several components of psychological pliability: the abilities to adapt to change, manage what comes along, handle stress, stay focused and think clearly, avoid getting discouraged in the face of failure, and handle unpleasant emotions such as pain, sadness, and anger ( Campbell-Sills and Stein, 2007 ). Each item is rated on a five-point range of responses. The total score is computed by getting the sum of all the responses whereby higher scores show high resilience ( Scali et al., 2012 ). Campbell-Sills et al. (2009) maintained that CD-RISC-10 has a median score of 32 with lowest to highest quartiles of 0–29 (Q1), 30–32 (Q2), 33–36 (Q3), and 37–40 (Q4) in general sample. As a widely used scale, CD-RISC-10 has achieved remarkable internal consistency of 0.89 in general population samples. It is both valid and reliable within the context of different cultures, including Filipino samples ( Campbell-Sills and Stein, 2007 ).

PERMA Profiler

The PERMA Profiler is a brief scale that measures the five pillars of well-being: positive emotion, engagement, positive relationships, meaning, and accomplishment, together with negative emotions and health ( Butler and Kern, 2016 ) along a 10-point Likert type scale. Of the 23 items, 15 correspond to the five core elements of well-being (three items per PERMA domain). In addition, eight items were included to test negative emotions (three items), physical health (three items), loneliness (one item), and overall well-being (one item). All items are expressed positively and higher scores denote better well-being except for negative emotions. Subscale scores are calculated by getting the mean of the three items on each subscale, except for loneliness. Overall well-being is calculated by averaging all items except those from the negative emotions subscale. The measure has been used in various samples and was found to have sufficient psychometric properties ( Cobo-Rendón et al., 2020 ). Butler and Kern (2016) reported that adequate reliability is observed for overall well-being and all subscales, α range from 0.71 to 0.94 across eight studies ( N = 31,966). According to Nebrida and Dullas (2018) , the Tagalog version of the PERMA Profiler has a Cronbach’s alpha of 0.842 in 101 Filipino participants.

In the current study ( n = 533), both PERMA Profiler ( α = 0.927) and CD-RISC-10 ( α = 0.915) have an “excellent” internal consistency. These results confirm that the scales are reliable tools for measuring elements of Well-being and Resiliency, respectively, in our sample.

Data Gathering Procedures

Data gathering lasted from March 23 to April 10, 2020, during the first reset of the nationwide extended ECQ. After securing individuals’ interest to take part in the study, we sent potential participants a link to the survey via Facebook Messenger. The first section of the Google Form shows the title of the research and an overview of the current study. After giving consent, participants could fill out the survey. Participants cannot answer the scales without explicitly agreeing to partake in the study. After securing informed consent, each participant was asked to provide their sociodemographic characteristics and then answer the PERMA Profiler and the CD-RSC-10. Answering both scales did not take the participants more than 20 min. After completing the questionnaire, each participant was virtually debriefed.

At any point, should a participant decide not to proceed with the research, they were free to do so with no implications. All the participant has to do was to close the Google Form window and any previously provided data were not recorded.

Data from Google Form were exported to IBM’s Statistical Package for Social Sciences (SPSS) and NCA Software for data analysis.

Data Analysis

Frequency and percentage were used to analyze the sociodemographic characteristics of the participants. We used Cronbach’s alpha to determine the internal reliability of the measuring scales. Correlation and multiple regression analyses were conducted to examine the relationship between PERMA elements and potential predictors of resiliency. Lastly, we used NCA to analyze whether the core elements of well-being are necessary but not sufficient conditions of resiliency.

There are two steps in NCA ( Dul et al., 2019 ), determining ceiling lines and bottleneck tables are the first. Unlike traditional regression models where a line is drawn through the middle of the data in an XY-plot, a ceiling line is created in NCA. This line distinguishes between areas with cases and areas without cases, the zone found in the upper left-hand corner of the plot. However, exceptions such as outliers and errors may be present in a sample so that the empty zone above the ceiling is not empty ( Karwowski et al., 2016 ). The ceiling line is a non-decreasing line (either a linear step function or a straight line) that shows which level of x (well-being elements) is necessary but not sufficient in producing the desired level of y (resiliency).

Dul (2016) identified two techniques in drawing the ceiling line. The first is the non-parametric Ceiling Envelopment with Free Disposal Hull (CE-FDH), which is a piecewise linear line. It is the default ceiling envelopment technique for NCA because it is flexible and intuitive and applies to dichotomous, discrete, and continuous conditions. The second technique is the parametric Ceiling Regression with Free Disposal Hull (CR-FDH), unlike the CE-FDH, this technique smoothens the piecewise linear lines by using a straight line. Because of this, CR-FDH usually has some observations above the ceiling line. Whereas CE-FDH does not. In further comparing the two techniques, CE-FDH is preferred when a straight line does not represent the data because smoothing reduces the size of the ceiling zone as with dichotomous variables and for discrete and continuous variables with relatively low small data sets. CE-FDH is 100% accurate in drawing the demarcation between observations above and observations below the ceiling line.

Quantifying the accuracy of ceiling lines, effect size, and statistical significance of the necessary conditions and necessary inefficiency are the second and final step ( Dul et al., 2020 ). The area of the empty zone above the ceiling line divided by the area where cases would be possible given the minimum and maximum values of X and Y is the effect size of a necessary condition ( Karwowski et al., 2016 ). Therefore, large effect size shows lower ceiling line and greater limitations that well-being elements have on resiliency. On the other hand, if there is a lack of empty space in the scatter plot then well-being elements are not contingents of resiliency. The effect size of a necessary condition can take the values between 0 and 1 where 0–0.1 corresponds to a small effect, 0.1–0.3 a medium effect, 0.3–0.5 a large effect, and d that is greater than 0.5 a very large effect ( Tynan et al., 2020 ). An R package that allows the calculation of various effect size indicators and inferential statistics useful for hypothesis testing is provided by Dul (2016) . The NCA null hypothesis is that the observed effect size is the same as the effect size calculated using random data ( Dul, 2019b ). An estimation of the probability that the observed necessary condition effect size results from comparing two unrelated variables, otherwise known as permutation test, is used to determine statistical significance in NCA ( Dul et al., 2020 ). Observed values of the x and y variables are randomly paired without replacement. Such pairing continues until the sample size is reached and the process is repeated at least 10,000. The resultant value of p is interpreted using traditional thresholds such as α = 0.05 or α = 0.01. Depending on the context of the research, both significance testing and effect size are useful in determining the theoretical and practical importance of an observed outcome ( Tynan et al., 2020 ). We focus our attention on conditions with both d > 0.5 and p < 0.05.

SPSS was used to analyze the frequency and percentage of various sociodemographic variables, the scales’ reliability, and for generating the Regression Model. R Statistical Software with NCA Package was used to conduct NCA.

Profile of the Participants

Participants comprised 376 females (70.56%) and 157 males (29.45%). The median and mode ages of the participants are 23 years, while the mean age is 25. Among the participants 189 (35.46%) were college students, 293 (54.97%) are employed, and 51 (9.57%) are out of work. Lastly, seven (1.31%) participants reported that they had direct contact with someone who was infected with COVID-19, while 100 (18.76%) reside in communities with known COVID-19 cases and 426 (79.92%) have no exposure to the disease.

PERMA as Predictors of Resiliency

Table 1 summarizes the descriptive statistics and analysis results of the study. Results revealed that the mean resiliency score of the participants is 24.83, with a SD of 7.22. PERMA elements including overall well-being are positive and significantly correlated with resiliency. Interestingly, a subjective sense of health (feeling good and healthy each day) showed only a weak, albeit significant positive correlation with resiliency. Negative emotions and loneliness are negatively correlated with resiliency.

Table 1 . Summary statistics, correlations, and coefficient results for regression analysis of study variables.

The multiple regression model with all nine predictors produced R 2 = 0.368, F (9, 523) = 33.83, p < 0.001 with adjusted R 2 = 0.357. This means that 36.8% of the variance in resiliency scores is because of the PERMA elements. As seen in Table 1 , accomplishment ( β = 0.447, p < 0.01) and negative emotions ( β = −0.171, p < 0.00) are the only elements of PERMA with significant regression weights, showing scores on these elements predict resiliency. However, negative emotions have significant negative weight as compared to with standardized coefficients of −0.171 vs. 0.477.

The multiple regression model of the four confounders between the relationship of PERMA elements and resiliency produced R 2 = 0.036, F (4, 528) = 4.90, p < 0.001 with adjusted R 2 = 0.028. It shows that the spread of the confounders is 3.6% between the relationship of the variables. As seen in Table 2 , only employment status (student, unemployed, and employed) with β = 0.14, p < 0.00 is a significant predictor of resiliency.

Table 2 . Confounders between the relationship of PERMA and Resiliency.

PERMA as Necessary-But-Not-Sufficient Conditions of Resiliency

The results of NCA on Resiliency show that all five elements of the original Seligman (2011) PERMA are necessary but not sufficient conditions of Resiliency among individuals who are community quarantined as showed by the size of the empty zone in the XY-plots in Figure 1 . This means that to score 35 in the CD-RISC-10, a score of 1 for positive emotions and engagement, a score of 2 for Positive Relationships, Meaning, and Accomplishment are necessary.

Figure 1 . Scatterplots of the original PERMA elements ( x ) as necessary conditions of resiliency ( y ). Note: The dashed lines are ceiling lines. The selected ceiling line technique (CE-FDH) do not allow data points above the ceiling line. The solid line is the ordinary least squares regression line.

Figure 2 contains the scatterplots of the four supplementary subscales of Butler and Kern (2016) PERMA Profiler. Only the xy-plot of Overall Well-being ( x ) and Resiliency ( y ) has a “moderately sized” empty zone in the upper left corner of the plot. This is not surprising considering that Overall Well-being is the composite score of the five PERMA elements and health score. The scatterplots of Health ( x ) and Resiliency ( y ), and Negative Emotions ( x ) and Resiliency ( y ) contain discernibly small empty zones. Lastly, the empty zone is absent in the Loneliness ( x ) – Resiliency ( y ) scatterplot. This assumes that Loneliness is not a necessary condition of Resiliency as the presence and size of an empty zone is a sign that a necessary condition is present ( Dul, 2016 ).

Figure 2 . Scatterplots of overall well-being, health, negative emotions, and loneliness ( x ) as necessary conditions of resiliency ( y ). These elements were not in the original Seligman (2011) PERMA model but are supplementary subscales in Butler and Kern (2016) PERMA Profiler. Note: The dashed lines are ceiling lines. The selected ceiling line technique (CE-FDH) does not allow data points above the ceiling line. The solid line is the ordinary least squares regression line.

We summarized the results of the multiple NCA in Table 3 . The observed accuracy of all variables exceeds arbitrary benchmark of Dul (2018) for the desired accuracy of 95%. Dul suggests the use of CR-FDH for interpreting variables with accuracies above 95%. However, since our variables do not follow a normal distribution ( p = 0.00) based on One-Sample Kolmogorov-Smirnov Test, we used the non-parametric CE-FDH ceiling line technique. Necessary-but-not-sufficient relationships between Resiliency and the five original PERMA elements and the auxiliary components are observed. The NCA effect size range between d = 0.09 and 0.12 based on CE-FDH for the original PERMA elements and d = 0.04 to 0.12 on the supplementary elements, excluding Loneliness. According to recommendations, Positive Emotions, Meaning, Accomplishment, and Overall Well-being of Dul (2016) have medium effect sizes on Resiliency. Engagement, Positive Relationships, Negative Emotions, and Health have small effect sizes on Resiliency. The NCA significance test is powerful enough to rule out an effect being the product of randomness ( Dul et al., 2020 ). Lastly, there is no necessary-but-not-sufficient relationship between Loneliness and Resiliency.

Table 3 . Necessary conditions effect size and significance test for PERMA Profiler subscales predicting Connor-Davidson Resiliency Scale-10 (CD-RISC-10) scores.

The ability to identify bottleneck variables (constraints) is a useful feature of NCA, especially for interpreting multivariate necessary conditions ( Dul, 2019b ). Table 4 , which is read horizontally, shows for which level of resiliency, which level of PERMA elements is necessary. For a desired value of resiliency, in the first column, it shows the minimum required values of the PERMA elements in the next columns. Levels are expressed in percentage ranges so that 0 is the minimum value, the maximum is 100, and 50 is the point between these two values.

Table 4 . Bottleneck table of PERMA elements as necessary conditions of resiliency based on CE-FDH.

The bottleneck table shows that no minimum value of any PERMA element is necessary to score 30% in Resiliency. This means that at 30% no PERMA element is a bottleneck for resiliency. However, for a resiliency level of 40%, the minimum required level of Positive Emotions is 6.9%, the necessary level of Accomplishment is 3.7, 7.1% for Overall Well-being, and none of the over PERMA elements are necessary. As observed in the bottleneck table, when Resiliency increases from 0 to 100%, more PERMA elements become necessary, and required levels of the PERMA elements become higher. At 90% level of Resiliency, the necessary level of Positive Emotions is 34.5%, Engagement is 18.6%, Positive Relationships is 25.9%, Meaning is 26.7%, Accomplishment is 25.9%, Overall Well-being is 34.2%, Health is 6.7%, and Negative Emotions is 42.9%. No level of Loneliness is necessary for any level of Resiliency. Not achieving any of these minimum levels means that attaining a 90% level in resiliency is impossible. Since each condition is a bottleneck, scoring higher in other elements does not compensate for the deficiency in others.

Wide range community quarantines and social distancing are elements that are increasingly becoming the new normal as a result of the global COVID-19 pandemic. Previous research ( Hawryluck et al., 2004 ; Barbisch et al., 2015 ; Brooks et al., 2020 ; Parmet and Sinha, 2020 ) offer invaluable insights into the psychological consequences of restrictions. Moreover, while there has been an interest in the psychological impact of COVID-19 and community quarantine in the Philippines (for example, Nicomedes and Avila, 2020 ; Tee et al., 2020 ), most focus on the negative psychological impact of COVID-19. This raises the question of what protective factors are important in the midst of prolonged community quarantines. To test this properly, we used a combination of the traditional regression model and the novel multivariate necessary-but-not-sufficient conditions analysis to investigate how resiliency is contingent on well-being elements in Filipinos who are community quarantined.

Participants of this study were predominantly female, around the age of 23 and who are employed. While, we specifically targeted individuals between the ages of 18–40, most of our sample are emergent adults (mean age = 25, median, and mode ages = 23). The disproportional representation of young adult females can be attributed to several factors. First, previous studies ( Smith, 2008 ; Yetter and Capaccioli, 2010 ; Slauson-Blevins and Johnson, 2016 ) have reported that young adult females take part in online surveys at a higher frequency compared with their male counterparts. There are more female Facebook users than males ( Lee et al., 2016 ), which is significant because we invited potential participants through Facebook. Lastly, the Philippines has a young population. The median age in the Philippines is 25.7 ( United Nations Statistics Division, 2019 ; Plecher, 2020 ). Taken together, it can be assumed that the sociodemographic characteristics of our study are similar to the Filipino Facebook population.

Based on the CD-RISC-10 quartiles for community sample provided by Campbell-Sills et al. (2009) , the mean resilience score (24.83) of the current sample belongs to the lowest 25%. This implies that the participants of the current study have lower resiliency scores than the general population. This result ties well with the notion that resilience is stress-context specific ( Jex et al., 2013 ; Wood and Bhatnagar, 2015 ; Hayman et al., 2017 ) and that the nature of the sample influences resiliency scores ( Connor and Davidson, 2003 ). Specifically, people with psychiatric problems and those who are experiencing significant stress score lower than the general population ( Li et al., 2012 ; Ye et al., 2017 ). In the context of COVID-19, Nicomedes and Avila (2020) found that Filipinos in community quarantine experience significant stress and scored high on both health anxiety and panic.

While resiliency and well-being have become commonplace terms and construct central in positive psychology ( Jeste et al., 2015 ), they are often studied using correlational methods ( Schultze-Lutter et al., 2016 ), and traditional approaches via the sufficiency paradigm. In line with previous studies ( Souri and Hasanirad, 2011 ; Khawaja et al., 2017 ; van Agteren et al., 2018 ), we found that all elements of well-being are positively correlated with resiliency. Although the multiple regression test shows that among the original PERMA elements, only accomplishment is a significant predictor of resilience. This means that the subjective sense of competence, having a structure each day, i.e., identifying, setting, and achieving daily goals enable resiliency in individuals subjected to quarantine. We also observed that negative emotions significantly, although negatively predict resilience. This suggests the significant predicting function of individuals’ tendency to experience anxiety and anger for lower levels of resilience. These findings support the previously reported ( Tugade and Fredrickson, 2004 ; Chen et al., 2018 ) link between negative emotions and low levels of resilience.

In this paper, we identified elements of well-being that are necessary-but-not-sufficient for resiliency to occur in individuals who are community quarantined. Specifically, Positive Emotions, Meaning, and Accomplishment are significant and moderately necessary conditions of Resiliency, as suggested by their medium effect size. This finding suggests that positive feelings like interest, joy, and contentment and pursuing a daily purpose, and regularly experiencing a sense of accomplishment are essential to quarantined individuals’ ability to thrive in their present predicament. Such necessary conditions not only allow individuals to enjoy everyday experiences ( Abiola et al., 2017 ) but also provide a sense that life matter, which replenishes depleted energy from adverse experiences, and are required in the development of resiliency.

Engagement and Positive Relationships have small yet significant effect sizes on Resiliency. This infers that experiencing a state of “flow,” or being absorbed in an activity ( Nakamura and Csikszentmihalyi, 2014 ) and feeling loved, supported, and valued by others are also necessary to the quarantined individuals’ capacity to recover quickly from their daily difficulties. This ties well with previous studies ( Eaude, 2009 ; Svence et al., 2015 ; Abiola et al., 2017 ; Gerino et al., 2017 ; Roncaglia, 2017 ; Cobo-Rendón et al., 2020 ), where well-being elements were observed to be related with the occurrence of resiliency in individuals from a different context. Well-being elements allow quarantined individuals to focus their attention on alleviating harm, preventing negative mental health consequences, and finding positive outcomes in the presence of difficulty.

A unique finding, we encountered is that PERMA elements are bottleneck variables of resiliency. This highlights the little-known capacity of well-being to serve as a constraint to attaining higher levels of resiliency in community-quarantined individuals. This novel result shows two things. First, low levels of resiliency (30% and less) do not necessitate even the slightest well-being elements. Second, higher levels of resiliency require certain levels of all the original PERMA elements and physical health. However, health remains a constant, albeit weak, necessary condition. This means that optimum resiliency is only possible when all the five pillars of well-being are taken care of and when one is at least minimally content with their physical health. When comparing our results to those of older studies ( Sanders et al., 2015 ; Svence et al., 2015 ; Abiola et al., 2017 ). It must be pointed out that while the link between well-being and resiliency has been suggested in these studies, none could establish the necessary-but-not-sufficient relationship between the concepts. The present findings underpin the importance of holistic rather than an atomistic approach to mental health as noted by Mario (2012) and contradicts the compensation hypothesis of well-being. NCA revealed that deficiencies in certain areas of well-being may not be addressed by overcompensating in other areas, as all five pillars of well-being are necessary-but-not-sufficient conditions of resiliency.

Our findings show that loneliness is inversely correlated with the subjective perception of health. This basic result is consistent with the research ( Balter et al., 2019 ) showing that loneliness predicts poor immune systems in healthy young adults. This is important since maintaining good health is vital amidst a growing viral pandemic. We observed that loneliness is a significant negative predictor of resiliency and not a necessary condition for any level of resiliency in individuals who are community quarantined. A similar conclusion was reached by Perron et al. (2014) where individuals who feel resilient also experience less loneliness. This further highlights the importance of the elements of well-being as necessary conditions of resiliency, which may lessen the effects of or serve as a buffer against loneliness and other negative psychological consequences of quarantine.

The overall results of our study have theoretical and practical implications. At a theoretical level, our results found clear support to PERMA concept of Seligman (2011) as necessary ingredients of resiliency even for socially isolated individuals such as those placed in ECQ. This goes beyond previous reports wherein PERMA elements were observed as predictors of resiliency, as only NCA can identify a necessary-but-not-sufficient relationship between the said variables. Despite experiencing segregation like lockdowns, the conditions that will allow people to thrive in the face of adversity are the same as when they are not undergoing such a predicament. Therefore, this finding can help us understand how the five elements of well-being constrain the negative psychological consequences of community quarantine by providing a buffer against these harms, reducing their effects, and promoting individual capacity to cope with such unsettling conditions. From this standpoint, we speculate that PERMA should be inversely correlated with negative indicators of mental health and correspondingly with other elements of positive psychological health, as noted by Hu et al. (2015) . At a practical level, this opens an opportunity to develop evidence-based interventions such as telepsychology ( Zhou et al., 2020 ) for quarantined individuals that help clients understand behaviors they need to engage to have resiliency, and target multiple necessary-but-not-sufficient variables jointly, and not just focus on certain elements of well-being. This provides support for eclectic approaches to therapy especially the ones that incorporate positive psychology as Bolier et al. (2013) noted empirical support for the effectiveness of such interventions. Lastly, our findings agree with the call to a more inclusive psychology in the Philippines. This paradigm shift involves incorporating such approaches as critical ( Paredes-Canilao et al., 2015 ) and positive ( Datu et al., 2018 ) psychology to the prevailing traditional pathology-based perspective.

One fundamental limitation of this study is that the use of multiple regression and NCA cannot guarantee causality ( Dul, 2016 ). While our data is consistent with the causal hypothesis, it is not evidence of a causal connection. Therefore, causal necessary-but-not-sufficient relations should not be inferred from our data. Another important caveat in interpreting our results is that we used the Facebook population as compared to the actual geographical population. It is not a perfect representative since Facebook users are usually younger females who have better educational attainment compared to the general population ( Kosinski et al., 2015 ). Resiliency and well-being were measured during the ECQ, a far from normal situation. Therefore, although we took obligatory safety measures to increase the trustworthiness of the findings, we suggest that care be exercised when generalizing our findings into the general population and normal circumstances.

Many questions remain to be answered concerning the well-being of people who are community quarantined and the utility of NCA in psychological research. Further work is needed to identify the negative consequences of prolonged quarantine on individuals, especially those who have preexisting mental health problems and those who experience a disruption in access to their mental health-care providers. Moreover Odacı and Kalkan (2010) reported that internet use, specifically social media ( Maglunog and Dy, 2019 ) exacerbates loneliness and that social media usage is expected to rise during the ECQ. Another important question, therefore, is how does the ongoing quarantine affects rates and levels of loneliness. Finally, while necessary conditions are traditionally studied using regression analysis in psychological research, NCA proved to be a more useful tool in understanding necessary-but-not-sufficient relationships because of its ability to understand bottleneck variables. We, therefore, recommend the use of NCA in both classical and novel psychological research problems.

Resiliency grants us the capacity to flourish in the face of difficulty. For resiliency to result, the pillars of well-being are essential. Our research reveals, however, that well-being elements could be enablers or constraints. Accomplishment, for example, could predict resiliency. All pillars are necessary to attain it. Compensating in certain aspects cannot address the deficiency in others. Herein lies the importance and significance of holistic well-being. Those who can attain this are better equipped to thrive in the ECQ, a situation that affects the lives of so many Filipinos.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Manila Tytana Colleges Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

DC wrote the introduction, results, and discussion and conducted the necessary condition analysis. LB wrote the methods, contributed in the results and discussion, and conducted the correlation analysis, regression analysis, and reliability check of the scales. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.558930/full#supplementary-material

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Keywords: positive psychology, well-being, resilience, PERMA, COVID-19, necessary conditions and sufficient conditions for optimality, necessary condition analysis, Philippines

Citation: Camitan DS IV and Bajin LN (2021) The Importance of Well-Being on Resiliency of Filipino Adults During the COVID-19 Enhanced Community Quarantine: A Necessary Condition Analysis. Front. Psychol . 12:558930. doi: 10.3389/fpsyg.2021.558930

Received: 04 May 2020; Accepted: 01 March 2021; Published: 22 March 2021.

Reviewed by:

Copyright © 2021 Camitan and Bajin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Desiderio S. Camitan IV, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Open Access

Peer-reviewed

Research Article

COVID-19 vaccine hesitancy and confidence in the Philippines and Malaysia: A cross-sectional study of sociodemographic factors and digital health literacy

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

Roles Data curation, Methodology, Project administration, Resources, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Community Medicine, International Medical School, Management and Science University, Shah Alam, Malaysia, Department of Community Medicine, Faculty of Medicine, Asia Metropolitan University, Johor Bahru, Malaysia, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

Roles Conceptualization, Data curation, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Psychiatry, Faculty of Medicine, University of Cyberjaya, Cyberjaya, Malaysia

Roles Conceptualization, Writing – original draft, Writing – review & editing

Affiliation Department: School of Criminal Justice Education, Institution: J.H. Cerilles State College, Caridad, Dumingag, Zamboanga del Sur, Philippines

Roles Conceptualization, Data curation, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia, South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

• Ken Brackstone, 
• Roy R. Marzo, 
• Rafidah Bahari, 
• Michael G. Head, 
• Mark E. Patalinghug, 

• Published: October 19, 2022
• https://doi.org/10.1371/journal.pgph.0000742
• Peer Review
• Reader Comments

With the emergence of the highly transmissible Omicron variant, large-scale vaccination coverage is crucial to the national and global pandemic response, especially in populous Southeast Asian countries such as the Philippines and Malaysia where new information is often received digitally. The main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify individual, behavioural, or environmental predictors significantly associated with these outcomes. Data from an internet-based cross-sectional survey of 2558 participants from the Philippines ( N = 1002) and Malaysia ( N = 1556) were analysed. Results showed that Filipino (56.6%) participants exhibited higher COVID-19 hesitancy than Malaysians (22.9%; p < 0.001). However, there were no significant differences in ratings of confidence between Filipino (45.9%) and Malaysian (49.2%) participants ( p = 0.105). Predictors associated with vaccine hesitancy among Filipino participants included women (OR, 1.50, 95% CI, 1.03–1.83; p = 0.030) and rural dwellers (OR, 1.44, 95% CI, 1.07–1.94; p = 0.016). Among Malaysian participants, vaccine hesitancy was associated with women (OR, 1.50, 95% CI, 1.14–1.99; p = 0.004), social media use (OR, 11.76, 95% CI, 5.71–24.19; p < 0.001), and online information-seeking behaviours (OR, 2.48, 95% CI, 1.72–3.58; p < 0.001). Predictors associated with vaccine confidence among Filipino participants included subjective social status (OR, 1.13, 95% CI, 1.54–1.22; p < 0.001), whereas vaccine confidence among Malaysian participants was associated with higher education (OR, 1.30, 95% CI, 1.03–1.66; p < 0.028) and negatively associated with rural dwellers (OR, 0.64, 95% CI, 0.47–0.87; p = 0.005) and online information-seeking behaviours (OR, 0.42, 95% CI, 0.31–0.57; p < 0.001). Efforts should focus on creating effective interventions to decrease vaccination hesitancy, increase confidence, and bolster the uptake of COVID-19 vaccination, particularly in light of the Dengvaxia crisis in the Philippines.

Citation: Brackstone K, Marzo RR, Bahari R, Head MG, Patalinghug ME, Su TT (2022) COVID-19 vaccine hesitancy and confidence in the Philippines and Malaysia: A cross-sectional study of sociodemographic factors and digital health literacy. PLOS Glob Public Health 2(10): e0000742. https://doi.org/10.1371/journal.pgph.0000742

Editor: Nnodimele Onuigbo Atulomah, Babcock University, NIGERIA

Received: June 12, 2022; Accepted: September 20, 2022; Published: October 19, 2022

Copyright: © 2022 Brackstone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are available on the OSF repository: https://osf.io/ncwjq/ .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

While many high-income settings have achieved relatively high coverage with their COVID-19 vaccination campaigns, almost 32.1% of the world’s population have not received a single dose of any COVID-19 vaccine as of July 2022 [ 1 ]. The Philippines and Malaysia are among two of the most populous countries in Southeast Asia with an estimated population of 110 million and 32 million people, respectively. To date, Malaysia has seen over 4.6 million cases with a mortality rate of 0.77%, while approximately 3.7 million cases of COVID-19 were detected in the Philippines with a mortality rate of 1.60% [ 2 ]. Malaysia is doing considerably well with their vaccination efforts, with 84.8% of the population currently considered fully vaccinated as of July 2022. However, vaccination campaigns in the Philippines have been more difficult, with 65.6% of the population fully vaccinated [ 3 ]. With the emergence of the highly transmissible Omicron variant across the world [ 4 ], large-scale vaccination coverage remains fundamental to the national and global pandemic response. Regular scientific assessments of factors that may impede the success of COVID-19 vaccination coverage will be critical as vaccination campaigns continue in these nations.

A key factor for the success of vaccination campaigns is people’s willingness to be vaccinated once doses become accessible to them personally. Vaccine hesitancy is defined by the World Health Organization (WHO) as the delay in the acceptance, or blunt refusal of, vaccines. In fact, vaccine hesitancy was described by the WHO as one of the top 10 threats to global health in 2019 [ 5 ]. Conversely, vaccine confidence relates to individuals’ beliefs that vaccines are effective and safe. In general, a loss of trust in health authorities is a key determinant of vaccine confidence, with misconceptions about vaccine safety being among the most common reasons for low confidence in vaccines [ 6 ].

Previously, vaccination in Southeast Asia has been associated with mistrust and fear, particularly in the Philippines, who are still suffering the consequences of the Dengvaxia (dengue) vaccine controversy in 2017 [ 7 ]. Studies suggest that this highly political mainstream event, in which anti-vaccination campaigns linked dengue vaccines with autism spectrum disorder and with corrupt schemes of pharmaceutical companies, continue to erode the population’s trust in vaccines. For example, a survey conducted on over 30,000 Filipinos in early 2021 showed that 41% of respondents would refuse the COVID-19 vaccine once it became available, whereas Malaysia reported 27% hesitancy [ 8 ]. Researchers predict that the controversy surrounding Dengvaxia may have prompted severe medical mistrust and subsequently weakened the public’s attitudes toward vaccines [ 7 , 9 ]. However, there may be many additional factors that weaken confidence in vaccines. For example, incompatibility with religious beliefs is one key driver of weakened confidence in vaccines [ 10 , 11 ], whereas living in urbanised (vs. rural) areas predicts COVID-19 vaccine hesitancy in some countries [ 12 – 14 ], possibly due to being more connected to the internet and social media and being more exposed to COVID-19-related misinformation.

Other predictors of vaccine hesitancy and confidence may include digital health literacy–one’s ability to seek, find, understand, and appraise health information from digital resources–and social media use. Research has shown that beliefs in available information is integral to perceptions of the vaccine safety and effectiveness [ 15 – 17 ]. Previous studies, for example, have associated higher vaccine hesitancy with misinformation about the virus and vaccines, particularly if they relied on social media as a key source of information [ 18 , 19 ]. Social Cognitive Theory (SCT) is a widely accepted theory which may explain individual behaviors, including digital health literacy [ 20 ]. SCT consists of three factors–environmental, personal, and behavioural–and any two of these components interact with each other and influence the third. As such, SCT can assist in establishing a link between one’s behaviour (e.g., information-seeking–one form of digital health literacy) and environmental factors (e.g., availability of information online), which may interact to promote medical mistrust and influence vaccine hesitancy and confidence (personal) [ 21 ]. Thus, health behaviours are often influenced by social systems as well as personal behaviours.

Although vaccine hesitancy and confidence are related concepts (e.g., people who express low confidence in vaccines are more likely to be vaccine-hesitant [ 6 ]), they are also distinct [ 22 ]. Thus, the main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify behavioural or environmental predictors that are significantly associated with both outcomes. Thus, developing a deeper understanding of the factors associated with vaccine hesitancy and confidence will provide insight into how specific population groups may respond to health threats and public health control measures.

Design, subjects, and procedure

This was an internet-based cross-sectional survey conducted from May 2021 to September 2021 in the Philippines and Malaysia. Snowball sampling methods were used for the data collection using social media, including research networks of universities, hospitals, friends, and relatives. Filipino and Malaysian residents aged 18 years or older were invited to take part. The inclusion criteria for participants’ eligibility included 18 years or older, and an understanding of the English language. All invited participants consented to the online survey before completion. Consented participants could only respond to questions once using a single account. The voluntary survey contained a series of questions which assessed sociodemographic variables, social media use, digital literacy skills in health, and attitudes toward the COVID-19 vaccine.

Ethical approval

The study received ethical approval from Asia Metropolitan University’s Medical Research and Ethics Committee (Ref: AMU/FOM/MREC 0320210018). All participants provided informed consent. All study information was written and provided on the first page of the online questionnaire, and participants indicated consent by selecting the agreement box and proceeding to the survey.

Demographics.

Filipino and Malaysian participants indicated their age category (18–24, 25–34, or 35–44), gender (man, woman), community type (rural, urban), educational level (no formal education, primary, secondary, tertiary), employment (unemployed, part-time, full-time), religion (Christian, Buddhism, Muslim, Hinduism, Other, None), income (1 = very insufficient ; 4 = very sufficient ; M = 1.84, SD = 0.81), whether they were permanently impaired by a health problem (no vs. yes), and whether they were social media users (no vs. yes).

Subjective social status.

Participant then rated their own perceived social status using the MacArthur Scale of Subjective Social Status scale [ 23 ]. Participants viewed a drawing of a ladder with 10 rungs, and read that the ladder represented where people stand in society. They read that the top of the ladder consists of people who are best off, have the most money, highest education, and best jobs, and those at the bottom of the ladder consists of people who are worst off, have the least money, lowest education, and worst or no jobs. Using a validated single-item measure, participants placed an ‘X’ on the rung that best represented where they think they stood on the ladder (1 = lowest ; 10 = highest; M = 6.23, SD = 1.86).

Vaccine confidence and hesitancy.

Participants were also asked about their perceived level of confidence in the COVID-19 vaccine (“I am completely confident that the COVID-19 vaccine is safe,” 1 = strongly disagree ; 7 = strongly agree; M = 4.57, SD = 1.48). Then, participants were asked about their level of hesitancy to the COVID-19 vaccine (“I think everyone should be vaccinated according to the national vaccination schedule”; no, I don’t know, yes). These questions were adapted from the World Health Organization, Regional Office for Europe survey [ 24 ]. The tool underwent evaluation by multidisciplinary panel of experts for necessity, clarity, and relevance.

Digital health literacy.

Finally, participants completed the Digital Health Literacy Instrument (DHLI) [ 25 ], which was adapted in the context of the COVID-HL Network. The scale measures one’s ability to seek, find, understand, and appraise health information from digital resources. A total of 12 items (three per each dimension) were asked, and answers were recorded on a four-point Likert scale (1 = very difficult ; 4 = very easy; α = .92; M = 2.15, SD = 0.59). While the original DHLI is comprised of 7 subscales, we used the following four domains, including: (1) information searching or using appropriate strategies to look for information (e.g., “When you search the internet for information on coronavirus virus or related topics, how easy or difficult is it for you to find the exact information you are looking for?”; α = .87; M = 2.15, SD = 0.65), (2) adding self-generated content to online-based platforms (e.g., “When typing a message on a forum or social media such as Facebook or Twitter about the coronavirus a related topic, how easy or difficult is it for you to express your opinion, thought, or feelings in writing?”; α = .74; M = 2.15, SD = 0.65), (3) evaluating reliability of online information (e.g., “When you search the internet for information on the coronavirus or related topics, how easy or difficult is it for you to decide whether the information is reliable or not?”; α = .86; M = 2.20, SD = 0.69), and (4) determining relevance of online information (e.g., “When you search the internet for information on the coronavirus or related topics, how easy or difficult is it for you to use the information you found to make decisions about your health [e.g., protective measures, hygiene regulations, transmission routes, risks and their prevention?”]; α = .87; M = 2.09, SD = 0.68). The reliability statistics for the overall DHL score was 0.92, while the alpha coefficients for the four subscales ranged from 0.74 to 0.87, suggesting acceptable to good internal consistency.

Data analysis

Data were examined for errors, cleaned, and exported into IBM SPSS Statistics 28 for further analysis. All hypotheses were tested at a significance level of 0.05. χ 2 tests were conducted for group differences of categorical variables, and Mann-Whitney tests for continuous variables. Subgroup analyses were performed for Filipino and Malaysian participants.

COVID-19 vaccine hesitancy and confidence were treated as separate dependent variables in a logistic regression model providing the strictest test of potential associations with COVID-19 vaccine hesitancy and confidence among Filipino and Malaysian participants. Low vaccine confidence was operationalised by dichotomising participants’ responses to the statement: “I am completely confident that the COVID-19 vaccine is safe” into those who disagreed or neither agreed nor disagreed (1–4), whereas high vaccine confidence was operationalised by dichotomising participants’ responses into those who agreed to some extent (5–7). Vaccine hesitancy was operationalised by dichotomising responses to the statement: “I think everyone should be vaccinated according to the National vaccination schedule” into those indicating ‘no’ or ‘I don’t know,’ whereas no vaccine hesitancy was operationalized by dichotomising participants’ response into those who indicated ‘yes.’

Independent variables were: age (18–24 vs. 25–34 vs. 35–44 [ref]), gender (women vs. men [ref]), community type (rural vs. urban [ref]), educational level (tertiary vs. secondary or less [ref]), employment (employed to some degree vs. unemployed [ref]), religion (Philippines: Christianity vs. Islam [ref]; Malaysia: Christianity vs. Buddhism vs. Hinduism vs. Islam [ref]), income (low (1–2) vs. high (3–4 [ref])), whether they were permanently impaired by a health problem (yes vs. no [ref]), whether they were social media users [yes vs. no [ref]), their perceived ranking on the MacArthur Scale of Subjective Social Status (continuous variable), and finally the four domains of the DHLI scale (all continuous variables).

A total of 2558 participants completed the online survey. Table 1 shows descriptive statistics of participants from the Philippines ( N = 1002) vs. Malaysia ( N = 1556). Filipino (vs. Malaysian) participants indicated higher rates of education ( p < 0.001), but were more likely to be unemployed ( p < 0.001). Further, Filipino (vs. Malaysian) participants were also more likely to indicate lower income ( p < 0.001) and rate themselves lower on subjective social status ( p < 0.001). Malaysian (vs. Filipino) participants were more likely to live in urban areas ( p < 0.001). Most notably, Filipino participants (56.6%) indicated higher prevalence of COVID-19 vaccine hesitancy compared to Malaysian participants (22.9%; p < 0.001). However, there were no significant differences between Filipino (45.9%) and Malaysian (49.2%) participants in ratings of vaccine confidence ( p = 0.105). Malaysian (vs. Filipino) participants were also more likely to report using social media (96.6 vs. 89.8%; < 0.001).

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Values are presented as percent (n) or means ± SD.

https://doi.org/10.1371/journal.pgph.0000742.t001

Table 2 shows significant predictors of vaccine hesitancy in both Filipino and Malaysian samples. Among Filipino participants, multivariate logistic regression analyses revealed that factors associated with higher vaccine hesitancy included women (OR, 1.51, 95% CI, 1.14–2.00; p = 0.004), residing in a rural community (OR, 1.45, 95% CI, 1.07–1.95; p = 0.015), and having lower income (OR, 1.62, 95% CI, 1.20–2.19; p = 0.001). Among Malaysian participants, women (OR, 1.51, 95% CI, 1.14–2.00; p = 0.004), being aged 25–34 (vs. 18–24; OR, 1.52, 95% CI, 1.48–2.21; p = 0.027), Christians (OR, 2.45, 95% CI, 1.66–3.62; p < 0.001), completing tertiary education (OR, 2.17, 95% CI, 1.63–2.88; p < 0.001), social media use (OR, 11.59, 95% CI, 5.63–23.84; p < 0.001), and information-seeking behaviours (OR, 2.50, 95% CI, 1.74–3.61; p < 0.001) were predictors of higher vaccine hesitancy, whereas having a health impairment (OR, 0.49, 95% CI, 0.30–0.78; p = 0.003) and higher self-reported ratings on subjective social status (OR, 0.82, 95% CI, 0.75–0.89; p < 0.001) were associated with lower vaccine hesitancy.

https://doi.org/10.1371/journal.pgph.0000742.t002

Table 3 shows significant predictors of vaccine confidence in both Filipino and Malaysian samples. Factors positively associated with higher vaccine confidence among Filipino participants included higher self-reported ratings on subjective social status (OR, 1.16, 95% CI, 1.07–1.25; p < 0.001), whereas factors associated with lower vaccine confidence included women (OR, 0.72, 95% CI, 0.54–0.96; p = 0.026) and information-seeking behaviours (OR, 0.63, 95% CI, 0.49–0.81; p < 0.001). Among Malaysian participants, factors positively associated with higher vaccine confidence included women (OR, 1.27, 95% CI, 1.18–1.60; p = 0.035), completing tertiary education (OR, 1.31, 95% CI, 1.03–1.66; p = 0.026), and higher self-reported ratings on subjective social status (OR, 1.08, 95% CI, 1.00–1.16; p = 0.036). Factors negatively associated with lower vaccine confidence included residing in a rural community (OR, 0.63, 95% CI, 0.47–0.87; p = 0.004), Christians (OR, 0.50, 95% CI, 1.20–2.24; p < 0.001), Buddhists (OR, 0.15., 95% CI, 0.10–0.22; p < 0.001), Hindus (OR, 0.24., 95% CI, 0.17–0.34; p = 0.004), information-seeking behaviours (OR, 0.42, 95% CI, 0.31–0.58; p < 0.001), and determining relevance of online information (OR, 0.68, 95% CI, 0.51–0.92; p = 0.013).

https://doi.org/10.1371/journal.pgph.0000742.t003

Malaysia and the Philippines are among the most populous countries in Southeast Asia. While the economic impact of the COVID-19 pandemic has been permanent in the Philippines, it has been shown thus far to be temporary in Malaysia [ 26 ]. Between January and October 2020, around 30,000 Malaysians had been infected by the virus with a mortality rate of 0.79%, while approximately 380,000 cases of COVID-19 were detected in the Philippines with a mortality rate of 1.9% [ 2 ]. Further, 61.8% of Malaysians had completed their vaccination up until September 2021, while the percentage of completed vaccinations during the same period in the Philippines was only 19.2% [ 27 ]. Vaccine uptake is likely to be a key determining factor in the outcome of a pandemic. Knowledge around factors which predict vaccine hesitancy and confidence is of the utmost important in order to improve vaccination rates. Thus, the core aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify behavioural or environmental predictors that are significantly associated with these outcomes.

First, while there were no significant differences in ratings of confidence in the COVID-19 vaccine between Filipino and Malaysian participants, Filipino (compared to Malaysian) participants expressed greater vaccine hesitancy. This may be a consequence of previous vaccine scares in the years leading up to the pandemic, including the Dengvaxia controversy in 2016 [ 7 , 9 ]. Systematic reviews demonstrated that, by the end of 2020, the highest vaccine acceptance was in China, Malaysia, and Indonesia [ 28 , 29 ]. The authors postulated that this elevated awareness was due to being among the first countries affected by the virus, hence resulting in greater confidence in vaccines [ 28 ].

Next, this study shows that women expressed greater vaccine hesitancy in both countries. The evidence base shows mixed findings, with other studies reporting higher hesitancy in women [ 30 ] or in men [ 31 ]. In some countries, the gender gap is not as substantial as others. In a large global study conducted in countries such as Russia and the United States, it was found that there is greater gender gap in vaccine hesitancy among men and women compared to countries such as Nepal and Sierra Leone [ 32 , 33 ]. Unsurprisingly, what drives this hesitancy is the inclusion of pregnant women, where studies have consistently demonstrated that this population is more hesitant toward vaccination due to concerns for their babies [ 34 ]. Hence, after taking all consideration into account, gender differences in vaccine hesitancy cannot be supported with certainty. This also emphasises the need for tailored health promotion towards the key populations at risk.

There are clear differences in predictors of vaccine hesitancy in the Philippines and Malaysia. However, when results for both countries were combined, women, urban dwellers, those of Christian faith, those with higher educational attainment, higher self-reported social class, social media use, and information-seeking tendencies remained as predictors of hesitancy. Urban-dwellers and individuals with more years of education have previously been demonstrated as predictors for vaccine hesitancy [ 35 ], but contradictory results have also previously been shown [ 36 , 37 ]. Urban residents are typically more connected to the internet and social media and, thus, may be more exposed to vaccine-related misinformation than rural inhabitants who have fewer sources of information available to them [ 12 – 14 ]. Nevertheless, reports have shown higher vaccine refusals among those with strong religious beliefs such as the Amish Community in the United States and the Orthodox Protestants in the Netherlands [ 38 ], as well as some Muslim groups in Pakistan [ 18 ].

Frequent social media use is the only strong predictor for vaccine hesitancy in this study, followed by information-seeking behaviours. Research has identified that the safety and effectiveness of the vaccine is the primary concern that people have, including beliefs in available information [ 15 – 17 ]. Unfortunately, high internet literacy is a double-edged sword, since participants in this study preferred to seek information through social media, and thus may have been exposed to inaccurate information regarding COVID-19 vaccine. Previous studies have associated higher vaccine hesitancy with misinformation about the virus and vaccines [ 18 ], particularly if they relied heavily on social media as a key source of vaccine-related information [ 19 ]. A 2022 systematic review discovered that high social media use is the main driver of vaccine hesitancy across all countries around the globe, and is especially prominent in Asia [ 39 ]. Furthermore, vaccine acceptance and uptake improved among those who obtained their information from healthcare providers compared to relatives or the internet [ 40 ].

In terms of vaccine confidence, our findings show that those with higher subjective social status have higher confidence in vaccination, consistent with previous studies describing how those with a higher income had expressed willingness to pay for their COVID-19 vaccination if necessary [ 32 , 41 , 42 ]. Further, those of Christian, Buddhist, and Hindu faiths, as well as those with a tendency to seek out information, were associated with lower vaccine confidence. This is in keeping with the previous findings demonstrating that strong religious convictions are often tied to mistrust of authorities and beliefs about the cause of the COVID-19 pandemic, which is fuelled by social media [ 43 ]. Furthermore, concern on the permissibility of these vaccines in their religion reduces its acceptability [ 10 ]. However, it is interesting to note that, while the majority in Malaysia are Muslims, it did not reduce the rate of vaccine acceptance and confidence in the country.

These findings have important implications for health authorities and governments in areas focusing on improving vaccination uptake. Misinformation about vaccination greatly hampers vaccination efforts. Thus, not only is it important to understand how specific population groups are influenced by digital platforms such as social media, but it is imperative to provide the right information driven by governmental and non-governmental organisations [ 39 ]. This could be achieved by having community-specific public education and role modelling from local health and public officials, which has been shown to increase public trust [ 44 ]. Since the primary reason for hesitancy is concern about the safety of vaccines, it is crucial that education programmes stress the effectiveness and importance of COVID-19 vaccinations [ 45 ]. Participants in this study coped with the pandemic by seeking out new information, but they sought information from social media when information from the authorities was lacking or were viewed as untrustworthy, which may have contained erroneous information. One way to deter this is to empower information-technology companies to monitor vaccine-related materials on social media, remove false information, and create correct and responsible content [ 44 ].

Furthermore, behavioural change techniques have been found to be useful in stressing the consequences of rejecting the vaccine on physical and mental health [ 46 ]. The most effective “nudging” interventions included offering incentives for parents and healthcare workers, providing salient information, and employing trusted figures to deliver this information [ 47 ]. Finally, since religious concerns have been prominent in reducing vaccine confidence and increasing hesitancy in this study, it is important to tailor messages to include information related to religion, and the use of religious leaders to spread these messages [ 48 ]. These are all important factors for increasing uptake of the COVID-19 vaccine, but also may be relevant in acceptability of routine immunisations as countries look to transition towards a post-pandemic delivery of healthcare.

A limitation of this study includes its cross-sectional design and the heterogeneity among participants, which meant that temporal changes in attitudes toward COVID-19 vaccines across time were not captured. Further, the need for internet access among Filipino and Malaysian participants limited the representativeness of the sample population. Thus, certain demographic were under-represented, including Filipino and Malaysian individuals over the age of 45, and people of lower socio-economic status. The surveys were also implemented in English, which may have limited the participation of target participants who were not fluent in English. In addition, due to space limitations, vaccine hesitancy and confidence were each captured using one item, which raises concerns of the items’ validity and reliability. Finally, not all independent variables were accounted for, including medical mistrust [ 49 ], vaccine knowledge [ 50 ], and specific social media platforms used [ 11 ]. We also did not assess whether participants had received any doses of the COVID-19 vaccine previously. Future research should include more important predictors to build a broader picture of vaccine-related hesitancy and confidence in the Philippines and Malaysia, and more items should be utilised to tap into these concepts more comprehensively. Despite these limitations, the core strength of this study relates to its relatively large number of participants from both countries, and its comprehensive analysis of predictors to provide as a starting point going forward.

Conclusions

The main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among unvaccinated individuals in the Philippines and Malaysia, and to identify predictors significantly associated with these outcomes. Predictors of vaccine hesitancy in this study included the use of social media, information-seeking, and Christianity. Higher socioeconomic status positively predicted vaccine confidence. However, being Christian, Buddhist or Hindu, and the tendency to seek information online, were predictors of hesitancy. Efforts to improve uptake of COVID-19 vaccination must be centred upon providing accurate information to specific communities using local authorities, health services and other locally-trusted voices (such as religious leaders), and for the masses through social media. Further studies should focus on the development of locally-tailored health promotion strategies to improve vaccination confidence and increase the uptake of vaccination–especially in light of the Dengvaxia crisis in the Philippines.

Supporting information

S1 file. inclusivity in global research questionnaire..

https://doi.org/10.1371/journal.pgph.0000742.s001

• 1. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus pandemic. Published online at OurWorldinData.org. Available from https://ourworldindata.org/covid-vaccinations .
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• 3. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C,Ortiz-Ospina E, et al. Philippines: Coronavirus pandemic country profile. Published online at OurWorldinData.org. Available from https://ourworldindata.org/coronavirus/country/philippines .
• 9. Mendoza RU, Valenzuela, S, Dayrit, M. A Crisis of Confidence: The Case of Dengvaxia in the Philippines. SSRN: doi: 10.2139/ssrn.3519736.

PINOY ABROAD

Mga bagong kaso ng covid-19 at active cases sa pilipinas, bumaba.

Nakapagtala ng 4,405 na mga bagong kaso COVID-19 sa Pilipinas ngayong Lunes, na mas mababa sa 5,279 na naitala nitong Linggo.

Sa datos ng Department of Health, lumitaw na natapyasan din ang bilang ng mga aktibong kaso, o mga pasyenteng ginagamot at nagpapagaling sa 57,763.

Mas mababa ito kumpara sa 60,957 active cases nitong Linggo.

Sa bilang ng mga aktibong kaso, nakasaad sa datos ng DOH na 76.2% ang "mild" cases, 6.5% ang "asymptomatic," 5.3% ang "severe," at 2.3% ang "in critical" condition.

Umabot naman sa 149 ang mga pasyenteng nasawi, mas mababa sa 208 na iniulat nitong Linggo.

Dahil dito, nasa 41,942 na ang naitatalang death toll ng COVID-19 sa Pilipinas.

Sinabi ng DOH na mayroong 118 kaso na dating nakalagay sa bilang ng mga gumaling ang inilipat sa bilang ng mga pumanaw matapos ang isinagawang final validation.— FRJ, GMA News

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• Open access
• Published: 10 May 2023

Determinants of COVID-19 vaccination decision among Filipino adults

• Lourdes Marie Sequerra Tejero 1 ,
• Rosemary Ruiz Seva 2 ,
• Bettina Joyce Petelo Ilagan 3 &
• Kattleea Lorezca Almajose 4  

BMC Public Health volume  23 , Article number:  851 ( 2023 ) Cite this article

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With a number of vaccines against COVID-19 now widely available globally, it is opportune to determine what tips the decision to get vaccinated. In most countries like the Philippines where the government provides these vaccines for free to all its citizens, their COVID-19 vaccine awareness and COVID-19 information sources as well as their socio-demographic profile were considered as primary factors that could possibly affect vaccination decisions. Participants’ income level was considered as a possible financial consideration that can affect vaccination decision as transport to vaccination sites might entail costs to them.

This study used a cross sectional survey design wherein participants came from all regions of the Philippines. An online questionnaire was voluntarily answered by Filipinos aged 18–80 years of age.

A total of 2,268 participated in the survey with 1,462 having complete responses which were included in the analysis. Those who are younger, with higher educational attainment, with public health insurance, with employers requiring vaccination, high awareness about COVID-19 vaccination, and high vaccine confidence are more likely to get vaccinated. On the other hand, those with long-standing illness and those residing outside the national capital region are less likely to get vaccinated.

Vaccination decisions among Filipinos are determined by their age, educational attainment, health insurance, employer requirement, high awareness of the disease, and a high level of vaccine confidence.

Peer Review reports

Introduction

On March 11, 2020, the World Health Organization (WHO), in a media briefing opening remarks by its director-general, characterized COVID-19 as a pandemic. While the development of vaccines is deemed as one of the most important responses to curb this global health crisis, WHO emphasized that it is vaccination per se, and not the vaccines that will put an end to this pandemic. However, WHO also acknowledged that there are challenges to ensure that people around the world get vaccinated.

In January 2021, the Department of Health of the Philippines issued an interim plan for the deployment of COVID-19 vaccines [ 1 ]. The strategy was that of a whole-of-society approach with the government leading the deployment of vaccines and implementation of the vaccination program. Of the 110 million population, about 70 million were considered eligible for the vaccines for 2021, based on pre-identified groupings.

Sallam [ 2 ] found out that vaccine hesitancy, or the “delay in acceptance or refusal of vaccination despite availability of vaccination services”[ 3 ], is considered as a common phenomenon globally. He furthers that, in his review of COVID-19 vaccine acceptance rates worldwide, vaccine hesitancy can be the major hindrance of the control efforts to lessen the negative consequences of COVID-19 pandemic, at least in certain countries/regions.

In the Philippines, decisions to get vaccinated, particularly of the COVID-19 vaccine, are driven by Filipinos’ concerns about having more information about the various vaccines available to them [ 4 ]. United Nations Development Programme (UNDP) Philippines, in August 2021 reported that the facilitating factors for vaccination included concern for family and loved ones, COVID-19 risk perception, approval of an endorsement by either the Food and Drug Administration (FDA) or the Department of Health (DOH), and work-related reasons; while barriers to vaccination included concerns about side-effects, medical reasons, news about vaccines, and vaccine effectiveness and efficacy [ 5 ]. It was mentioned in this same report that COVID-19 vaccination in the Philippines started in March 2021 and that by August 15, 2021, around 40.4 to 44.1% of the adult population have received at least one COVID-19 vaccine shot. The Philippine government’s initial target was 70% of the population by the end of 2021.

Despite these findings, however, several factors affecting decisions to get vaccinated against COVID-19, given the multifaceted nature of vaccine hesitancy [ 2 ] and the history of vaccine uptake in the Philippines marked by critical challenges [ 6 ] required further studies.

Hence, this quantitative, correlational research on the determinants of COVID-19 vaccination decision among Filipino adults. As transport to vaccination sites might entail costs for people, participants’ income level was considered as a financial factor that can affect their vaccination decision. Non-financial factors considered were socio-demographic characteristics; COVID-19 information sources, awareness, and worry; and vaccine confidence and functional health literacy. The study examined if both these financial and non-financial factors could determine participants’ vaccination decision.

Research design

This is a cross sectional survey design wherein participants from all the 17 administrative regions of the Philippines were included in the sample. Following the formula provided by Bujang, et al. [ 7 ], the required number of participants is 850.

Data collection was conducted in the first quarter of 2022, the time when a recent surge of cases was declining early in that quarter [ 8 ], and when the Philippine government is nearing its target of vaccinating 70% of its population against COVID-19 [ 9 ]. It was opportune at this time to investigate the drivers for actual vaccination. Participants of the study were Filipinos aged 18–80 years old, currently residing in the country, were qualified to take the COVID-19 vaccine, could read, and understand Filipino and/or English, and could answer the questionnaire online.

Two questionnaires were developed in two languages: English and Filipino. The English questionnaire was translated from English to Filipino by a qualified translator. The English questionnaire was piloted first to 25 individuals to ensure the clarity of questions. Corrections were made on the format of the questionnaire and order of questions. After translation, the Filipino questionnaire was piloted to another 25 people. The Filipino version was revised to simplify the difficult Filipino terms used in the first version.

The survey was administered online using two methods: first is self-administered (91%) and the second was by a trained research assistant interviewer (9%) for those who were in remote areas and had difficulty accessing the Internet. The main survey questionnaire administration was conducted between March to April of 2022. Participation in the study was voluntary. Recruitment was done through social media platforms and through email. Participants were given an online survey link and they had the option to answer either a questionnaire in English or a questionnaire in Filipino. Answering the questionnaire and subsequently submitting it, constituted participant’s consent in the study. Those who requested reimbursement for the internet services incurred in answering the online questionnaire were reimbursed accordingly. The responses to the questionnaire remained anonymous since the request for reimbursement came in separately from the questionnaire. All the questions in the questionnaire were mandatory.

A questionnaire was designed ad hoc to collect the data for this research. The sociodemographic data included age, sex, educational attainment, employment status, income level, health insurance, health status, and region of residence.

Employer requirement for vaccination and advice by a health care provider to vaccinate against the disease are binary variables in the model where a yes answer was coded as 1. Information sources included three items that identify a person’s social context - family and friends, co-workers, and healthcare workers. Nine items that describe their information environment - government agencies, TV, newspaper, radio, Facebook, Instagram, Twitter, TikTok, and YouTube. The frequency of access followed a five-point Likert scale measured as (1) never, (2) rarely, (3) sometimes, (4) often, and (5) always. For COVID-19 vaccination awareness, participants were asked to answer a 9-item quiz-type survey with statements formulated based on information presented on the websites of the Philippines’ Department of Health and the United States of America’s Center for Disease Control and Prevention. The three levels of awareness were given scores as follows: 1 (correct information), 0 (unaware of the information), and − 1 (wrong information) in the model.

COVID-19-related worry was determined using a three-item scale taken from Head et al., [ 10 ] to measure participants’ personal worry about COVID-19. A 5-point Likert-type scale was used where 1 = strongly disagree to 5 = strongly agree.

Participants’ vaccine-related profiles included information on functional health literacy (FHL) and vaccine confidence. All four items to measure FHL were taken from Biasio et al., [ 11 ]. As for vaccine confidence , five items were adapted from the 8-item Vaccine Confidence Scale by Gilkey et al., [ 12 ] measured using a 10-point sliding scale from 0-strongly disagree to 10-strongly agree because of their relevance to study objectives. The 5 items included were: (1) Vaccines are necessary to protect health, (2) Vaccines do a good job in preventing the diseases they are intended to prevent, (3) Vaccines are safe, (4) If I get vaccinated there can be serious side effects and, (5) In general, medical professionals in charge of vaccinations have my best interest at heart. Item 4 was reverse coded.

Participants’ vaccination status is a binary variable where one refers to getting the full dose of the vaccine or at least one shot of a two-dose vaccine. Their vaccination status equated to their vaccination decision, considered as the dependent variable in the model.

Data analysis

Aside from age, all sociodemographic data were considered categorical variables in the model. Coded data was processed using MS Excel and scored. Responses with scores were summed and used in calculating the total scores of vaccination awareness, COVID-19-related worry, FHL, and vaccine confidence. Sociodemographic data were summarized using a frequency table. Quantitative data were presented as mean and standard deviation. Binary logistic regression (BLR) was performed to determine predictors of COVID-19 vaccine decision. The BLR model was constructed by including all 15 covariates at the same time. A full model was constructed that included all the variables in the analysis. This approach was used to prevent bias in the selection of variables to be included in the model.

Data were analyzed using SPSS 21.0 (IBM Corp.: Armonk, NY, USA). Significance level considered was 0.05.

Ethics statement

All methods were carried out in accordance with relevant guidelines and regulations. Since all participants were 18 years old and above, the consent of a guardian was not required. The introductory letter to participants in the survey questionnaire contained relevant information about the research including objectives, benefits to the participant, anonymity, expected time for their participation, utilization of data gathered, contact information of the researchers, etc. It also indicated that participation was voluntary and continuing to answer the survey was an expression of consent. The study protocol, survey questionnaire, including ‘waiver of informed consent documentation’ were reviewed and approved by the University of the Philippines Manila’s Review Ethics Board, with code UPMREB 2021-0673-01.

A total of 2,268 participated in the survey from which 1,462 complete survey responses were recorded and analyzed. Incomplete responses were not included in the data analysis. A response is considered incomplete if the respondent failed to finish the survey.

Participants’ sociodemographic characteristics

Table  1 summarizes the sociodemographic characteristics of the 1,462 participants in the study. When data gathering was conducted, around 70% of the Philippine population had already been vaccinated. Participants came from all the regions in the Philippines but the distribution of the sample did not follow the actual geographical distribution. 61% (61%) of the participants came from densely populated areas in the Philippines, such as CALABARZON (25%), National Capital Region (20%), and Central Visayas (16%). Participants aged 21–30 comprised the highest percentage of the sample (36%), followed by those younger than 21 (20%). People older than 60 comprised 6% (6%) of the sample only. 69% (69%) of the sample were female. Approximately two-thirds (66%) were college graduates, and 54% were employed. More than half (52%) belong to the poor and low-income group, and 47% have no health insurance. Eighty one percent (81%) do not have a long-standing illness.

Participants’ COVID-19-related Profile

Most (86%) of the participants were either partially or fully vaccinated. Seventy one percent (71%) received a recommendation from a healthcare professional to get a COVID-19 vaccine. Of the 785 employed participants, 83% were required by their employers to get vaccinated against the disease.

As can be seen in Table  2 , the average awareness score is 2.81 indicating that participants know at least 3 correct COVID-19 vaccine information. Details of the COVID-19 Awareness data were included in Annex 2. Majority (93%) are aware that the vaccines are free, that they come in different brands (89%) and they are effective in helping protect against severe disease and death (83%). However, around 96% are not aware that vaccines have side effects that are normal and believe that it contains microchips that can alter DNA (89%).

The mean FHL score indicates a general difficulty understanding published information about COVID-19 vaccines. The participants are highly worried about getting infected by the virus but have high levels of confidence in the vaccine.

Table  3 summarizes the sources and frequency of access to COVID-19 vaccination information. The top three most often accessed sources of information on COVID-19 vaccination are Facebook, TV, and family and friends.

Sociodemographics, COVID-19-related Profile, and vaccine-related Profile Associated with Vaccination decision

The results of the binomial logistic model of the sociodemographic, COVID-19-related profile and information sources are presented in Table  4 . Logistic regression analysis was performed to explore the influencing factors associated with the decision to get vaccinated against the COVID-19 virus. Younger age (aOR = 0.94, 95% CI = 0.92–0.96), higher educational attainment (aOR = 5.25, 95% CI = 2.75–10.03; aOR = 6.22, 95% CI = 2.14–18.13), those with public health insurance (aOR = 2.47, 95% CI = 1.23–4.96), those with employers requiring vaccination (aOR = 4.28, 95% CI = 2.18–8.43), high awareness about COVID-19 vaccination (aOR = 1.22, 95% CI = 1.11–1.34), and high vaccine confidence (aOR = 1.15, 95% CI = 1.12–1.19) are more likely to get vaccinated. Those with long-standing illness tend not to get vaccinated (aOR = 0.38, 95% CI = 0.19–0.76). As for the region of residence, those regions outside the national capital region (NCR) are less likely to get vaccinated.

Several socio-demographic variables significantly affect the vaccination decision of participants in the sample. Results suggest that young participants are more likely to take the vaccine as the proportion of unvaccinated individuals increases with age. This is consistent with previous findings that young people are less hesitant to receive the COVID19 vaccine [ 13 , 14 ]. During the survey, health authorities in the Philippines struggled to vaccinate its elderly population because they do not turn up at the vaccination sites, meeting only 5% of the target during a three-day vaccination drive [ 15 ]. One of the reasons cited by health authorities is the belief of older adults that they do not have many years to live, making the vaccine unnecessary[ 16 ]. Some elderly people are also difficult to reach, especially those living in rural areas [ 16 ].

Higher education levels such as college and postgraduate degrees, largely determine vaccination decisions in this study. A closer look at the data showed vaccine awareness and functional literacy levels are lower for those without college degrees. Literature on vaccine determinants worldwide consistently showed that fewer years of education decreases the chance of COVID19 vaccine uptake [ 17 , 18 ]. People with higher education have heightened awareness of the risks and benefits of the vaccine because they have more knowledge about the vaccine and the vaccination process. Similarly, high vaccine acceptance rates among college students in China were associated with high knowledge [ 19 ].

Sex, employment status, and family income were unrelated to the study’s vaccination decision, probably because the Philippine government made COVID-19 vaccines free for all its citizens; thus, financial incapacity and unemployment did not deter anyone from getting vaccinated. Men and women received the vaccines to comply with institutional requirements. Our study showed that employers requiring COVID-19 vaccination increased Filipinos’ likelihood of vaccinating. The Presidential announcement requiring vaccination for employees working onsite [ 20 ] strongly influenced the people’s decision to get the shots. For the unvaccinated, their options were to work from home or undergo regular RT-PCR testing as prescribed by the Philippine Department of Labor and employment [ 21 ]. With the high costs of tests, employees generally opted to get vaccinated.

Geographic location has a strong association with vaccination uptake since the Philippines is an archipelago consisting of more than 7,000 islands. Delivering the vaccines to far-flung areas from the National Capital Region (NCR) is a logistical challenge that contributes to the difference in vaccination rates across areas. During the time of the vaccine rollout, local government units (LGUs) interviewed from Luzon, Visayas, and Mindanao expressed concerns about vaccine handling, especially the need for cold storage facilities and vehicles to transport the vaccines [ 22 ]. Aside from logistical problems, the Geographically Isolated and Disadvantaged Areas (GIDA) in the Philippines are also affected by the pandemic response due to communist terrorist groups in the area [ 23 ].

The participants came from all the regions of the country although the distribution of the sample did not reflect the actual geographical distribution. The participants lived mainly in highly urbanized areas whereas the Philippines has more rural communities. NCR is the center of the country’s economic activity and the largest of all metropolitan areas. The likelihood of getting vaccinated decreases as the region gets further away from the NCR as urbanization significantly determines the vaccine acceptance rate [ 24 ]. In Canada, more people were vaccinated in large metropolitan areas, just like the NCR [ 24 ]. Moreover, population density is generally higher in urban areas, especially in the NCR, making the people more concerned about disease transmission.

Vaccine awareness of participants in this study is generally high as most lived in urban areas. There was high awareness in NCR and Luzon. People who live far from the capital and/or urban areas may have less access to information materials and modalities, hence the lower vaccination uptake in these areas. Two common mistakes emerged from our results about COVID19 vaccines. Most participants believed that they do not have to take the full dose of the vaccine and that vaccines can alter or change their DNA, turning them into genetically modified human beings. The false information about DNA modification lowered vaccine acceptance and was found to be one of the most common themes in a study of 52 countries about vaccine rumors and conspiracy theories [ 25 ]. Taking only the first of a 2-dose COVID-19 vaccine gives protection for a limited period. The second dose prolongs the duration of this protection by activating the helper T cells of the immune system [ 26 ].

Participants who know about vaccine brands, compositions, and doses, as well as vaccination effectiveness and side effects after vaccination being considered normal, have a higher tendency to decide to get vaccinated than those with little or no knowledge of these things. Nomura et al. [ 27 ] also found that people’s perceptions of the risks and benefits of a COVID-19 vaccine were significantly associated with their vaccination intention. These findings imply that for vaccination intention and eventually vaccination decision to increase, people should be made aware of the benefits of availing the COVID-19 vaccine.

Having misconceptions about the vaccine strongly correlated with the study participants’ not getting vaccinated. This is corollary of their most frequently cited source of information which was Facebook where fake news abound [ 28 ]. Moreover, the moderate level of functional health literacy of the participants reflects the difficulties they may have in discerning false from true information. Thus, more effective and targeted information dissemination schemes are needed to address this situation.

People with long standing illness were not likely to get vaccinated against COVID 19. Vaccine hesitancy remains to be an issue among those with health problems. Reluctance is due to lack of understanding, fear of adverse effects, and negative COVID-19 Vaccination information [ 16 ]. In the Philippines, more than a quarter of those aged 35–59 years have been diagnosed with illnesses that predispose them to serious effects of COVID-19 [ 29 ]. With the community quarantine focusing more on these high-risk groups, they are more susceptible to such fear and reluctance.

The level of vaccine confidence among the participants is high. Those who indicated that the COVID-19 vaccines are safe and needed to protect one’s health were more likely to get vaccinated. The lowest confidence rating was related to the vaccine’s side effects, followed by doubt about its safety. Findings of similar studies in Japan and South Korea showed that the most cited reasons for low vaccine confidence were side effects and that vaccines had not been sufficiently tested [ 30 ]. The decline in the COVID19 vaccine confidence in the Philippines may have been influenced by the Dengvaxia vaccine fiasco in 2017. The controversy caused the vaccine confidence of Filipinos to decline from 93% to 2015 to 32% in 2018 [ 31 ]. Traumatic experiences concerning previous vaccination and information obtained from traditional, social media, and neighbors further contribute to delay and refusal of vaccination [ 32 ].

Those who have public health insurance are more likely to get vaccinated. Since the COVID-19 vaccination program for the whole Philippines is government-funded and controlled, those with public health insurance may be more familiar with the public health system and may be able to access the COVID-19 vaccination program.

The results of this study have implications for the public health approach to increasing COVID-19 vaccinations. Since the younger ones are more inclined to get vaccinated, they may serve as the conduit to reach the older ones, especially the hesitant people with chronic illnesses, as they are more at risk of contracting COVID-19. The government can increase the vaccination rate of older people by offering packages to incentivize young people taking their older parents for vaccination. Since the lines for vaccination are usually long, a young person together with a person aged more than 50 years old may be in the priority lane.

Results also indicate that the educated and those with higher awareness levels of COVID-19 are more likely to get vaccinated. This is consistent with the findings of previous studies [ 33 , 34 ]. Since the community quarantine is easing up and people can go out of their homes, information, education, and communication (IEC) materials should be designed for the less educated people and be situated in locations where these people frequent like the streets, bus stops, and the like. Around 72% of Filipinos have access to a smartphone [ 35 ] so the government can possibly tie up with telecommunications companies to spread crucial information through text messages about COVID-19 vaccination and correct false information from social media. This can be especially effective for those in the rural areas where information through the media may be harder to reach. Thus, for rural areas the IEC materials may be placed in locations and settings where people usually congregate, like in the market, plaza, municipal hall, and the like.

Study findings showed that participants actively sought for COVID-19 vaccination information from Facebook, TV, and family and friends almost every week. This result implies that there is a need for concerned officials to fill their Facebook pages and posts with information related to their respective COVID-19 vaccination programs. In this case, individuals who can acquire these pieces of information can share these with family and friends who seek the same from them.

The study should also provide an impetus for the government to provide the infrastructure and equipment for better vaccine deployment for COVID-19 and other potential disease outbreaks in the future. The US Agency for International Development pledged USD 315 million for cold chain facilities and mobile vaccination sites to reach far flung areas in the Philippines [ 36 ]. This is a short-term solution to address current needs; however, the government has to strategically plan and identify supply chain solutions at the national level such as providing roads, bridges, and basic infrastructure especially to underdeveloped areas.

This study’s results are comparable to the findings in countries near the Philippines. In Malaysia where the government also purchased their vaccines against COVID, about two-thirds of the respondents were willing to get vaccinated. They were those from the lower age group, those with higher education, females, and not having chronic disease. Moreover, the strongest drivers for their decision to get vaccinated were vaccine effectiveness and suggestions from their Ministry of Health [ 37 ]. In China on the other hand, those who were older, had a lower education level, lower income, higher trust in the vaccine and higher perceived risk of infection showed a higher probability to vaccinate [ 38 ]. There is a greater proportion of older people in China than in the Philippines or Malaysia which may explain the differing results in terms of age. There are also differences in literacy rate which may account for the different results. What is common among these countries is that the perceived effectiveness of the vaccine is the main driver for people to get vaccinated.

The present study was conducted in the second year after the start of the pandemic when the Philippines had gone through peaks of the COVID-19 infection that claimed thousands of lives. The vaccine seemed to be the only hope to avoid deaths. Moreover, people needed to work for their sustenance. Even those who were previously hesitant to get vaccinated, did so because it was required by their employers [ 20 ]. Thus, the proportion of those who got vaccinated is high. As the threat of COVID-19 waned with the increased herd immunity, there is a decreased uptake of the booster doses of the vaccine [ 39 ]. It is foreseen that there may be an eventual decline in the uptake of the biannual booster shots. Unless there is an effective campaign not only from the medical community but more importantly from the government, people will not take the succeeding doses of the vaccine. This study offers some directions in devising campaign strategies based on the factors influencing decision to vaccinate against COVID-19.

Limitations for this present study include using purposive sampling in recruiting participants instead of probability sampling because of the constraints brought about by the pandemic situation. The link to the survey was sent to contacts and institutions all over the country through electronic means. Researchers ensured that respondents came from all the 17 regions in the country, representing the different categories of the main variables of this study. There were difficulties in finding unvaccinated individuals as the proportion of the vaccinated went over 80% in the NCR. With the collaboration of enumerators from different regions, an adequate number of unvaccinated people were eventually included in the study, approximating the proportions in the regional levels. Potential bias in the collection of data by enumerators from various regions may have happened but this was minimized with the proper orientation of the enumerators.

Online questionnaires naturally are accessible by those with the appropriate gadgets and internet access, thus potentially limiting the inclusion of those with low resources. To mitigate this, the researchers offered to refund the internet fees incurred by respondents. Moreover, the enumerators aided those who were old, illiterate, and without gadgets to record their responses on their own devices. Thus, there were some respondents from these categories who were able to participate in this study.

Based on the findings of the study, it can be concluded that among Filipino adults, COVID-19 vaccination decision is determined by their age, educational attainment, health insurance, and employer requirement. Further, it can be concluded that a high awareness of the disease and a high level of vaccine confidence correlates with the decision to get vaccinated.

Accessing the true information about the disease and vaccine is key in reaching the decision to get vaccinated. It also contributes to high levels of vaccine confidence. Thus, effective information dissemination schemes targeted according to the socio-demographic profile, health literacy and sources of information of the intended audience will result in better vaccine uptake.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The researchers are grateful to all the enumerators from the different regions of the Philippines in effectively collecting data from the respondents.

The publication of this paper is funded by the De La Salle University Manila and the Engineering Research and Development for Technology (ERDT) of the Philippine government. The research was partially funded by Cavite State University.

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Lourdes Marie Sequerra Tejero

Industrial and Systems Engineering, De La Salle University, Manila, Philippines

Rosemary Ruiz Seva

College of Arts and Sciences, Cavite State University, Indang, Cavite, Philippines

Bettina Joyce Petelo Ilagan

Lyceum of the Philippines University Manila, Manila, Philippines

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LMST, RRS and BJPI conceptualized and wrote the protocol of the research. KLA, BJPI, LMST, RRS collected data. RRS and LMST statistically analyzed the data. LMST, RRS, BJPI, KLA wrote the article, reviewed and edited the final manuscript.

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Correspondence to Lourdes Marie Sequerra Tejero .

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Tejero, L.M.S., Seva, R., Petelo Ilagan, B. et al. Determinants of COVID-19 vaccination decision among Filipino adults. BMC Public Health 23 , 851 (2023). https://doi.org/10.1186/s12889-023-15712-w

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DOI : https://doi.org/10.1186/s12889-023-15712-w

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Filipinos' health information-seeking behaviors and their implications for COVID-19 vaccination

Affiliations.

• 1 College of Nursing, University of Santo Tomas, Manila, Philippines.
• 2 Mental Health Nursing Department, College of Nursing, University of Ha'il, Ha'il City, Saudi Arabia.
• 3 School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia.
• 4 School of Nursing, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia.
• PMID: 34902170
• DOI: 10.1111/phn.13034

Objectives: This study examined Filipinos' health information-seeking behaviors, specifically their information engagement and apprehension of getting the COVID-19 vaccine, the reasons for vaccination, and how these factors influenced their decision to get vaccinated.

Design: Quantitative, cross-sectional, and predictive approaches.

Sample: This study conducted a national online survey using convenience sampling (n = 2709).

Measurement: The Health Information Orientation Scale (HIOS) and Statista.com's "reasons for not getting a COVID-19 vaccination" were used to collect data. Demographic characteristics that predict information engagement and apprehension were identified using multivariate linear regression analysis.

Results: Responses to information engagement and apprehension revealed "often true" and "sometimes true," respectively. The majority of participants intended to receive the COVID-19 vaccine. "Concerned about the vaccine's safety" is the most common reason for not getting vaccinated. Female gender, college graduate, employed, and using social media to obtain COVID-19 vaccine information were all significant predictors of information engagement and apprehension. Information engagement and apprehension were predicted by age and religion, respectively.

Conclusions: Policymakers should consider how people seek information regarding the COVID-19 vaccine and why some people refuse to get vaccinated. Additionally, public health nurses should educate the public about the safety of COVID-19 vaccines.

Keywords: COVID-19 vaccine; Filipino; health information-seeking behavior; information apprehension; information engagement; vaccination decision.

© 2021 Wiley Periodicals LLC.

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Responding to COVID-19 Through Socialist(ic) Measures: A Preliminary Review

When the covid-19 outbreak was declared a global pandemic, countries stepped up efforts to contain the spread of the virus. some countries resorted to socialist(ic) measures ranging from nationalizing private hospitals to state-supervising face mask factory operations, and from freezing prices of basic commodities to suspending rent, mortgage, and utilities payments., authored by filipino department professor dr. david michael san juan, the paper aims to document and describe these measures, as a springboard for arguing that the global capitalist status quo should be transformed/replaced if humanity is to survive this and future global pandemics..

The Ethics of Scare: COVID-19 and the Philippines’ Fear Appeals

To motivate people to take preventive measures against the spread of COVID-19, the Philippine government has resorted to tactics that play on people’s fears. In this discussion note, the authors ask whether these “fear appeals” or “scare tactics” are morally justifiable.

Authors: Philosophy Department Associate Professors Dr. Hazel Biana and Jeremiah Joven Joaquin

Can Global Pharmaceutical Supply Chains Scale Up Sustainably for the COVID-19 Crisis?

Pharmaceutical companies around the world are racing to develop vaccines and antivirals to combat the pandemic. but given the magnitude of the disease, supply chains will face many challenges to meet the demand for these medicines., chemistry department full professor dr. derrick ethelbhert yu, chemical engineering full professor dr. luis razon, and vice chancellor for research and innovation and university fellow dr. raymond girard tan discuss the high likelihood of global shortages of treatments and vaccines developed for covid-19..

Modeling the Economic Impact and Ripple Effects of Disease Outbreaks

Dlsu school of economics associate professor dr. krista danielle yu and chemical engineering full professor dr. kathleen aviso offer new insights in their peer-reviewed and indexed research work on the covid-19 pandemic, one of the country’s first covid-related studies., once the covid-19 pandemic is controlled, the tasks of rebuilding and redesigning industrial networks are needed to better withstand future outbreaks., watch video:.

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Lessons in Survival

Patrick david cenon, assistant professorial lecturer, this article identifies seven salient lessons from real-life survival situations which are maybe applied in business and management during the time of the covid-19 pandemic..

Learning and Development in the New Normal

This article suggests that in the new normal, learning and development professionals can focus their efforts on four items: purpose, customer, content and process..

Employee Engagement in the New Normal

This article points out the importance of identifying the different types of employees, understanding their behavior and anticipating their needs to allow leaders and managers to properly respond and engage their employees in the new normal..

How COVID-19 threatens online freelancing in the PH – and what can be done

Dr. jason cabañes and prof. cheryll soriano of the communication department, for this piece, the authors draw on their four years of research on the viability of digital freelancing across philippine cities, including their ongoing work funded by the university research coordinating office (urco)..

Duterte’s COVID-19 Powers and the Paradox of the Philippine Presidency

International studies department full professor dr. julio teehankee contributes to “corona chronicles: voices from the field”, an initiative of the kyoto university’s center for southeast asian studies. dr. teehankee’s article discusses transgressing the boundaries of presidential power amidst the covid-19 pandemic..

Coronavirus: The Story of Risk and Resilience Parts 1 and 2

Chemical engineering department full professor dr. michael angelo promentilla notes that as the government starts crafting the policy for the exit strategy after the enhanced community quarantine, metrics for risk and resilience are needed to gain much-needed clarity on relevant actions to win the war against the pandemic..

READ ARTICLE:

Confronting the new normal in seafaring

International studies department associate professor dr. ron vilog writes about how the global seafaring industry is facing rough waters ahead due to the covid-19 pandemic..

Productivity during the Enhanced Community Quarantine

Behavioral science department assistant professorial lecturer patrick david cenon gives suggestions on how we can be productive during the enhanced community quarantine..

‘Yorme, Yorme’: Modeling themes from COVID-19 concerns and public reports aired through Manila City government Twitter accounts.

The study discusses the implementation of thematic analysis of covid-related concerns and reports sent by locals of manila city found in mayor isko moreno and manila pio’s twitter accounts. the results of the analysis show four major themes that the local government of manila can focus on to create data-driven decisions and improve public services during this time of pandemic., author: joseph marvin r. imperial, ms computer science student.

https://medium.com/@josephimperial/yorme-yorme-modeling-themes-from-covid-19-concerns-and-public-reports-aired-through-manila

Coronavirus: Ang Maso at ang Sayaw

De la salle university chemical engineering full professor dr. michael promentilla provides the filipino version of “coronavirus: the hammer and the dance.”, this follows “coronavirus: why you must act now,” an article describing the urgency of the covid-19 pandemic. the article has generated more than 40 million views and translated into over 30 languages..

READ ARTICLE: https://medium.com/@mpromentilla/coronavirus-ang-maso-at-ang-sayaw-a71482bda34f

POLICY BRIEFS

<center></p> <h6>see more policy briefs</h6> <p></center>, strengthening provincial supply chain management capacity for covid-19 vaccines.

Authors: Romulo F. Nieva, Yolanda R. Robles, Christine Aileen Benosa, & Anthony Rosendo Faraon

This eighth issue of our policy brief examined the supply chain management (scm) practices of three philippine provinces. it assessed the different aspects of their vaccine scm, from management up to their delivery. based on the assessment, the paper outlined insights and recommendations on coming up with a coherent strategy to ensure the efficient administration and delivery of vaccines in the country., click to read the article, digital transformation and covid-19: policy imperatives for local governments and msmes in the philippines.

The sixth issue of our policy brief prepared by  Dr. Sherwin Ona  and  Ms. Samantha Ching  discusses how digital transformation (Dx) strategies can provide new ways of energizing the country’s supply chain and customer relationship management to address the fallout arising from the COVID-19 pandemic. Likewise, is discusses how Dx can improve public services through online systems that will encourage citizens and businesses to transact with the government within the safety of their homes. Finally, this policy brief proposes a Dx roadmap for local policymakers, local government executives, and entrepreneurs with a new perspective on how to use Dx to create stronger integration of local governments and Micro, Small, Medium-scale Enterprises (MSMEs).

Reintegrating overseas filipino workers amidst the covid-19 pandemic.

The fifth issue of our policy brief, prepared by Dr.  Ma. Divina Gracia Z. Roldan , discusses the Philippine government’s response to the plight of returning Overseas Filipino Workers in light of the COVID-19 pandemic. It discusses some of the measures the national government took to address the needs of returning OFWs due to the pandemic. As well, it discusses how different stakeholders can play a role in potential areas for policy intervention. Finally, it explores possible long-term solutions needed to reintegrate OFWs displaced by this global health crisis.

The covid-19 crisis and the philippine coffee msmes: status and prospects (consumer demand).

This La Salle Food and Water Institute policy brief details several recommendations that are drawn from inputs from respected representatives of the local coffee value chain supplemented by data collected from a consumer survey. This endeavor also serves as a genuine pilot case that would address the challenges mentioned in the DTI’s 2017 Policy Brief regarding the Philippines in the Coffee Global Value Chain, specifically: 1) Lack of coordination among industry stakeholders, and; 2) Gaps in collection and distribution of research and technical knowledge.

Authors: jose carlos martinez, ronald yu, raphael garcia, lennard joseph reyes, ma. theresa domine, angela ferreria-tan, michelle gladys sy, jade cleo galera, and dr. emmanuel garcia, covid 19 in the philippines: potential implications in modernizing the armed forces of the philippines.

The fourth issue of our policy brief, prepared by Dr. Sherwin E. Ona and Dr. Rodolfo A. Tor, underscores the need for the Philippines to reexamine its national security agenda and review the new AFP modernization program (AFPMP) in line with its current experiences related to the COVID 19 pandemic and the “new normal.” This entails a reevaluation of the current AFP philosophy on military operations other than war (MOOTW), its impact on Humanitarian Assistance and Disaster Relief (HADR) readiness, and its obvious link to chemical, biological, radiological and nuclear (CBRN) defense principles.

Recommending a patient-level study to confirm that bcg vaccination accounts for the relatively low covid-19 mortality rate in the philippines.

Sharing the latest AKI Policy Brief from the Responding to the Covid-19 Pandemic series written by Dr. Arnulfo Azcarraga, University Fellow and Full Professor of the College of Computer Studies.

The brief recommends a patient-level study to investigate whether bcg vaccination can explain the relatively low covid-19 mortality rate in the philippines noting that in countries which never had mass bcg vaccination experience relatively higher death rates due to the coronavirus disease., learning with friends:  a rational view of remote learning with network externalities in the time of covid-19.

by:  Dr. Dickson A. Lim, Associate Professor, Economics Department and Paul John M. Peña, Professional Lecturer Economics Department

The authors provide a rational view of the issue of online learning in the time of coronavirus and cite necessary conditions that must be considered to make remote learning optimal, inclusive and engaging for students and faculty.featuring a model of human capital accumulation with network externalities, the policy brief maintains that “…in the time of coronavirus, learning need not be quarantined, too.”, setting up a health communication strategy for local government units during the  covid-19 pandemic: insights and recommendations.

The third issue of the Policy Brief outlines some suggestions in establishing an effective health communication strategy for Philippine local government units (LGUs) in response to Covid-19. Effective risk and health communication plays a crucial role and gives an opportunity to help their constituents understand and adopt protective behaviors during a health emergency such as a pandemic.

Authored by cheryll ruth r. soriano, jan michael alexandre c. bernadas, felipe f. salvosa iii,  ador r. torneo, and carlo magno p. figueroa, setting up a covid-19 community response strategy in local government units:  immediate, transitory, and medium-term considerations for planning.

This policy brief from the Jesse M. Robredo Institute of Governance outlines some policy considerations for local government units (LGU), specifically provinces, cities, and municipalities, currently drafting or revisiting their COVID-19 Community Response Strategy and the accompanying local measures.

Authored by torneo, a.r., andres, a.a., berse, k.b., borja, a.l, nazareno, r.s. ordoñez, m.d., rayo, j.a.b., recio, r.b., salvosa, f.f. soriano, c.r.r.10, setting up a community response strategy for local government units: practical advice for reorienting existing systems to deal with covid-19.

This policy brief Jesse M. Robredo Institute of Governance highlights practical considerations for local government units (LGU), specifically provinces, cities, and municipalities, currently drafting or revisiting their COVID-19 Community Response Strategy and the accompanying local measures. It integrates some of the lessons from innovative practices, observations, and inputs from JRIG’s volunteer group of professionals.

Authored by torneo, a.r., andres, a.a., berse, k.b., borja, a.l., nazareno, r.s. ordoñez, m.d., rayo, j.a.b., recio, r.b., salvosa, f.f., soriano, c.r.r., the economic impact of the metro manila (ncr) enhanced community quarantine.

This Angelo King Institute of Economic and Business Studies policy recommendation on tempering the negative economic impact brought about by the government-imposed enhanced community quarantine.

This is co-authored by dr. krista danielle yu, dr. kathleen aviso, and dr. raymond girard tan., potential economic effects of lockdown in the philippines due to covid-19: lessening the impact on poor households.

The authors recommend providing direct income support and targeting the support to vulnerable labor groups in critical sectors. This may be channeled  through the government’s 4Ps. Furthermore, they recommend that, if the lockdown is extended to three months, an additional support of PhP 70 billion is considered to reverse the change in all poverty indicators prioritizing our worst hit sectors such as agriculture, textile-garments, and construction.

This angelo king institute of economic and business studies brief is co-authored by dr. caesar cororaton, dr. marites tiongco, and dr. arlene inocencio of the dlsu school of economics., preparing for shortages of covid-19 drugs: a data-based model for optimal allocation.

 Future approved COVID-19 drugs will be short in supply until global production capacity is built up to meet demand. It is necessary for health administrators to exercise sound judgement in allocating a very scarce resource.

Allowing entry of foreign health professional in containing the covid-19 pandemic in the philippines.

In light of the risks posed by COVID-19 on Filipino health care professionals, this Angelo King Institute of Economic and Business Studies policy brief recommends short-term solutions that may support in containing the outbreak and at the same time mitigate the risks.

Authored by dr. tereso tullao, jr., john paolo rivera, and dr. cynthia caudia, covid-19 diaries: a millennial collection (new entry).

This was created by a group of millennials, composed of faculty and students from De La Salle University and Ateneo de Manila University which aims to document the different events that occurred prior to, during, the after the COVID-19 pandemic.

Covid-19 diaries week 8 (jun 01mo – 07su) new entry, covid-19 diaries week 7 (may 25mo – 31su), covid-19 diaries week 6 (may 18mo – 24su), covid-19 diaries week 5 (may 11mo – 17su), covid-19 diaries week 4 (may 04mo – 10su), covid-19 diaries week 3 (apr 27mo – may 03su), covid-19 diaries week 2 (apr 19su – 26su), covid-19 diaries week 1 (apr 12su – 18sa), health and safety of patients of frontliners make filipinos worry.

By Dr. Crisanto Q. Regadio, Dr. Marlon D.L. Era, and Mariane Amor Romina T. Abuan

Faculty members of the college of liberal arts conducted a nationwide study to better understand the social and psycho-social impact of the implementation of the enhanced community quarantine from march 15 to may 15, leading evidence-based actions through data science for health security and resilience consortium .

The LEADS for Health Security and Resilience Consortium is composed of professionals from the academe, civil society, private sector coming together in the wake of the evolving COVID-19 pandemic. The group aims to harness data science and analytics against the COVID-19 pandemic toward promoting health security and resilience in the country.

Chemical engineering department full professor dr. michael angelo promentilla is a member of the consortium. his concept proposal, co-inform risk scoring dashboard, is one of the featured prototype products of the consortium., to know more about co-inform risk scoring dashboard, visit the consortium’s link at:  http://covid19.psphp.org/, ph tool app.

Crowdsourcing tool to map COVID-19 symptoms

Faculty and students from the Laguna campus of De La Salle University recently developed a crowdsourcing tool to map COVID-19 symptoms. Initiated by University Fellow Dr. Arnulfo Azcarraga, Associate Vice Chancellor for Campus Development Jay Calleja, and BS CS-ST student Cyrus Vatandoost Kakhki, the tool allows the public to share data then see possible patterns of symptoms from the community map generated. Submitting data only takes 10 seconds.

Click the link:  https://symptom-tracker. tedhouse.org/, liferisks and hopelab@dlsu online well-being self-evaluation during the covid-19 outbreak.

LifeRisks and the Psychology of Hope and Well-Being Lab at DLSU (HopeLab@DLSU) launched the online survey (#GPULSECOVID19) where participants can answer a short self-report questionnaire and get a preliminary report on their general mental health (e.g., stress, anxiety) and also positive resources (e.g., social support, hope), among others. Participants who are indicated to have mental health symptoms are automatically sent mental health self-help tips and links to professional services they can consult.

The members of the #gpulsecovid19 research team are norman mendoza, adrian paul liangco, john ian wilzon dizon, and leandro david from liferisks and dr. allan b. i. bernardo of hopelab@dlsu., the survey is available in filipino and english..

Filipino:  https://bit.ly/ WellBeingSelfEvaluation-FIL English:  https://bit.ly/ WellBeingSelfEvaluation-ENG

Post-Pandemic Recovery Modelling  School of Economics Associate Professor Dr. Krista Danielle Yu

How will the economy recover after the covid-19 pandemic school of economics associate professor dr. krista danielle yu will discuss models for assessing the pandemic’s impact and identify the vulnerable economic sectors in a webinar titled “post-pandemic recovery modelling.” organized by the philippine-american society of science and engineering, the webinar will be held on april 24, friday, at 8:00 am., research projects.

Policy Development for COVID-19 Pandemic Response Using System Dynamics

Authors: dr. charlle sy, ezekiel bernardo, angelimarie miguel, jayne lois san juan, andres philip mayol, phoebe mae ching, dr. alvin culaba, dr. jose edgar mutuc, and dr. aristotle ubando., the covid-19 outbreak has led countries to implement control strategies such as the enhanced community quarantine, travel bans, and social distancing, with varying levels of success. this presentation raises policy recommendations through a system dynamics modelling approach for possible course of actions to mitigate the transmission of covid-19. the dynamics of several policies are analyzed and assessed based on effectiveness in mitigating infection and the resulting economic strain..

Optimal Locations and Allocation of Personnel (OLAP) at Checkpoints during the Coronavirus Lockdown and Manual Development for the Preparation of Future Pandemics in Metro Manila and other Regions

A project developed by dr. alexis fillone, dr. joel ilao, and dr. robert billones, this study looks at how to optimally allocate both healthcare and security personnel at checkpoints surrounding metro manila and to develop guidelines on this subject in preparation for future pandemics in the country., this research is supported by the department of science and technology-philippine council for industry, energy and emerging technology research and development, de la salle university, all content is in the public domain unless otherwise stated..

ABOUT COVID-19 Research Portal

Welcome to de la salle university’s  covid-19 research and resource portal. this site lists the research works, activities, and initiatives of faculty members, research centers, students, and other university units that are related to the study of the coronavirus pandemic., dlsu research links.

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Junctures in the time of COVID-19: Topic search and government's framing of COVID-19 response in the Philippines

Rogelio alicor l panao.

University of the Philippines Diliman, Philippines

Ranjit Singh Rye

This article argues that, like many in Southeast Asia, the Philippine government's COVID-19 response was marked by policy experimentation and incremental adaptation, having been caught off-guard by the pandemic. Examining 16,281 government press releases related to COVID-19 issued by the Philippine News Agency between February 2020 and April 2021, we find that in its policy narratives the government panders initially to citizen demand, highlighting social amelioration as a pandemic strategy. However, as citizens’ economic anxiety further intensifies, the government's framing of the crisis response becomes pragmatic and turns towards promoting mass inoculation, ostensibly in a bid to convince citizens to choose health over short-term palliative economic measures. The findings nuance policymaking in an illiberal democracy, beyond the conventional populist description of seeking easy solutions or spectacularizing crisis response.

Just as prospects were getting rosy for the Philippine economy, bad news arrived. On January 22, 2020, the first COVID-19 infection in the Philippines was detected in two Chinese nationals visiting the country ( Edrada et al., 2020 ). On February 2, 2020, the first confirmed death due to the virus was reported ( Marquez, 2020 ). By March, the virus had taken the lives of 24 more additional patients and brought the number of cases to 380. By April that year, confirmed cases in the Philippines were running up to four digits.

The government's immediate response to the pandemic focused on minimizing its socioeconomic impact and restarting the economy. For instance, on March 23, 2021, Congress passed Republic Act 11469, the Bayanihan to Heal as One Act, granting the president, inter alia, temporary emergency powers to impose community lockdowns and providing cash assistance to displaced workers and low-income families. Essentially a “social amelioration initiative,” the Bayanihan Act was a direct response to the World Health Organization's (WHO) recommendations ( Vallejo and Ong, 2020 ) to an economy thrown into its worst recession since the Second World War. While there were variations in subsequent implementing policies, within government the consensus seemed to have been towards balancing economic growth with public health. However, by the end of the first quarter of 2021, amidst a sudden surge in COVID-19 cases, the government's official policy response took a complete turn towards procuring ample vaccines and inoculating the public.

What causes policy response to turn from palliative interventions to pragmatic options? For resource-challenged governments conveying their policy narratives to the public in response to crises, what motivates the choice between economic viability and securing vaccines? Can citizens’ interest in an event or crisis spur policy learning amidst a lack of adequate opportunity to establish a response strategy?

This article argues that, like many in Southeast Asia, the Philippine government's COVID-19 response was marked by policy experimentation and incremental adaptation, having been caught off-guard by the pandemic. While it is well known in the public policy and political science literature that public opinion can shape public policy ( Wlezien and Soroka, 2016 ); the bulk of the literature is usually in the context of interest groups, political parties, and elites, not ordinary citizens, and not with respect to experiences outside the USA ( Burstein, 2003 ). As for the policy implications of the COVID-19 pandemic, on the other hand, the growing and emerging body of research is largely focused on epidemiological aspects such as the spread of the disease and compliance to health measures ( Brodeur et al., 2021 ). There is also scant scholarly introspection on causal explanations pertinent to the governance component of pandemic policies beyond an organizing framework ( Maor and Howlett, 2020 ).

Using the dynamics of the Philippine government's COVID-19 response as a case study, we argue that citizen concern on economic dislocations during the pandemic has a dynamic effect on how the government frames contentious policies whose redistributive implications can undermine government legitimacy. As anxious citizens seek information on the pandemic, the government panders to what it believes to be a response desired by the public and frames its COVID-19 policy around social assistance as a defining narrative. However, as mounting anxiety reveals the public's uncertainty with concurrent policy, the framing of the crisis response becomes rational and shifts towards the promotion of more viable options, such as mass inoculation. To support our conjecture, we analyzed 16,281 press releases on COVID-19 issued by the Philippine News Agency (PNA) between February 2020 and April 2021, and juxtaposed them with citizens’ COVID-19-related search interest based on Google Trends. Utilizing topic modeling and econometric techniques, we find that the government panders to citizen demand for economic safety nets in its policy narratives but only up to a point, and ultimately shifts to promoting mass inoculation as economic anxiety worsens.

The findings provide an evidence-based facet of policymaking in a precarious democracy criticized for lackluster pandemic intervention. The international media, for instance, initially branded the Philippine COVID-19 response a “tragedy of errors” ( Beltran, 2020 ). While there is arguably a basis for this view, our findings suggest nevertheless that there was an attempt by the government to be responsive, even if such responsiveness meant pandering to public sensitivities with respect to weighing policy alternatives. There was also policy learning, as shown by how the government pragmatically reoriented its policy narrative from economic support to mass inoculation, after heightened interest in social transfers made it realize that population immunity is more cost effective in the long run.

The article proceeds as follows. We begin by expounding on the relationship between crises and policy change as the focus of theoretical and empirical introspection in the literature. Afterwards, we elaborate on our theory explaining why the government's COVID-19 policies were shaped by policy adaptation and experimentation. We also explain why we expect informational citizenship to induce the government to turn from a reactive policy that is narrowly focused on providing economic assistance to one that targets population immunity. This is followed by a discussion of the data, measures, and estimation approach we employed to test our conjecture. We then discuss the results and how they nuance current understanding of the government response to the COVID-19 crisis. The article concludes with the broader implications of the findings on pandemic policymaking.

Policymaking and policy shifts

There is a policy change or shift when one that is existing is replaced with something new and innovative, or undertakes incremental refinements ( Bennett and Howlett, 1992 ). Political dynamics, problems, and proposal may be construed as streams capable of suddenly changing government policies ( Cairney and Jones, 2016 ). During crucial periods, these streams may create an opportunity or condition in which agenda change is possible. Referred to as policy windows, these critical junctures open an array of choices to policy actors, allowing decision making to become more significant ( Capoccia and Kelemen, 2007 ; Donnelly and Hogan, 2012 ). Punctuated equilibrium occurs when abrupt and radical policy changes arise after a long period of stability ( Jones and Baumgartner, 2012 ). Bennett and Howlett (1992) , for their part, argue that states learn from experiences and modify decisions based on how well previous measures performed in the past. This policy learning serves as a platform for future decisions and these are circulated as new information to achieve political goals and create policy-related beliefs over time ( Moyson et al., 2017 ).

There are competing views on policy learning but there is almost scholarly consensus regarding the role of social forces in policy change. An indication of learning happens when there is a shift in policy, even though the preferred policy is not necessarily the most efficient ( Hall, 1993 ). Sometimes the government learns simultaneously while responding to circumstances or crises through key societal actors who create conditions that state officials must address ( Bennett and Howlett, 1992 ). Policy learning, according to Greener (2002) , takes place at various stages—those that take place at the level of policy instruments, and those that involve a shift where policymakers reject their own ideas and adopt another. Whereas policymakers are often responsible for the former, the broader social and political forces are the driving factors behind paradigmatic shifts ( Berman, 2013 ).

A robust strand of literature also construes policy change as a product of the confluence of three elements—institutions, interests, and ideas ( Béland, 2009 ; Shearer et al., 2016 ). Institutions refer to the formal and informal rules, norms, beliefs, and precedents that shape the policy response to a crisis ( Mahoney, 2000 ). Interests, on the other hand, reflect the policy choices, material motivations, and agenda, not just of policy actors (elected officials, civil servants), but even of those operating outside the government (societal groups, researchers, policy entrepreneurs) and their desire to influence the policy process to attain their own ends ( Kern, 2011 ; Prechel and Boies, 1998 ). Meanwhile, ideas refer to knowledge or belief about what is (scientific or factual knowledge), what ought to be (values), or a combination of these ( Pomey et al., 2010 ). Ideas can become decisive causal factors in policy change if there are considerable institutional impediments that weaken the capacity of political actors to promote the adoption of a concrete policy alternative ( Béland, 2009 ).

However, institutions, ideas, and interests are not mutually exclusive. Policy change can generally be caused by a shift in one, or their combination, and alter the structure of a policy network. For ideas to be realized, for instance, there have to be advocates. Interests, on the other hand, need to be able to modify behavior to attain the survival of ideas by contending or cooperating with other interests. In the context of the policy process, ideas may reflect ideological considerations or citizens’ values. Ideology and values, in turn, are gauged empirically by looking at how public opinion plays a role in the diffusion or modification of policies. Wlezien (1995) , for instance, conceives a model of public responsiveness in which citizens behave like a thermostat that sends a signal to the government when policy deviates from their preference so that this policy can change accordingly. Supposedly, critical public opinion ceases once policy is in congruence with citizen demand.

COVID-19 response as policy adaptation and experimentation

Existing works on the politics of the COVID-19 response in the Philippines have ubiquitously highlighted policy failure in the backdrop of a populist regime ( Aguilar, 2020 ; Hapal, 2021 ; Teehankee, 2021 ). However, such preoccupation with populism as a one-size-fits-all account not only hampers a more nuanced examination of policy discourse ( De Cleen and Glynos, 2021 ) but ignores the relevance of citizens as stakeholders and policy participants ( Kweit and Kweit, 2004 ). This article digresses from the conventional populist formula and contributes through an empirical inquiry of the relationship between citizen demand and policy response.

Like many in Southeast Asia during the early phase of the pandemic, the Philippines’ response to COVID-19 was fidgety, imperfect, and disproportionate. Dewi et al. (2020) note that public officials with very limited information dealt with the pandemic through a plethora of policy strategies that were not necessarily the most effective. These disproportionate policy reactions are a form of policy overreaction driven by the challenges that elected officials faced while coordinating extant policy strategies and collecting public health information. In search of the most effective response, governments repeatedly undertake a trial-and-error process of agenda setting, formulation, implementation, and evaluation, while exploring multiple policy possibilities. At crucial junctures, policy problems, their solutions, and the political environment converge and pave the way for an intervention that is acceptable to the public. But because resources vary by country, governments also take different approaches in their struggle with the pandemic. Inevitably, they may also be constrained by balancing the need to secure citizens’ economic well-being with managing shocks to the healthcare system.

Studies such as those by Purnomo et al. (2022: 2) characterize the Philippines’ COVID-19 response as underreactive, or one in which there is “a systematic stagnant or inadequate response by government officials to high risks or no response at all.” Interestingly, countries which underreact to the pandemic also exhibit rapid COVID-19 transmission. Policy reaction, however, is not just a function of economic or institutional readiness. Dewi et al.'s (2020) findings imply, for instance, that overall collective opinion and well-being is related to the manner by which policymakers respond to the pandemic.

Our theoretical premise construes citizens’ pocketbook assessment of economic uncertainty under COVID-19—operationalized by their search interest on the pandemic—as catalyzing a critical juncture, and applies it in the context of the COVID-19 response in the Philippines ( Figure 1 ). In our view, this juncture is capable of triggering a learning or realization process on the part of policymakers that allows incremental or small changes in policy through problem-solving approaches ( Dunlop and Radaelli, 2013 ; Flink, 2017 ) and is reflected in policy narratives. We follow Moyson et al. (2017) and construe this learning process as having both cognitive and social components in which information and experience are used to inform, substantiate, or legitimize policy beliefs and objectives ( Bennett and Howlett, 1992 ; Dunlop and Radaelli, 2013 ).

Public's search interest and government's shifting policy narrative on COVID-19.

In this framework, stakeholder and citizen engagement feedback are valuable sources of policy learning, especially in the changing governance setting of governments grappling with COVID-19 as a critical juncture. We consider critical juncture as “a situation of extreme challenge and uncertainty” where institutional and social policies and practices have the propensity to result in fundamental change ( Twigg, 2020 ). We contribute by providing empirical support to the notion of crisis as critical juncture and as a causal determinant of policy shifts, using the Philippine government's COVID-19 policy response as a case study.

As is perhaps the case elsewhere, policy response to COVID-19 in the Philippines was relegated to a specialized technical group that operated autonomously and made policy decisions that were often insulated from political factors. Accordingly, policy actions concerning COVID-19 routinely proceeded from a single source and had been, to borrow from the punctuated equilibrium literature, “in a relative state of equilibrium” ( Amri and Drummond, 2020 ). The Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF-EID) is the body primarily responsible for all matters concerning emerging infectious diseases, such as swine flu and the novel coronavirus. The IATF-EID was convened in January 2020 but it was neither ad-hoc nor new, having been created through Executive Order 168 issued by former president Benigno Simeon Aquino on May 26, 2014.

Since COVID-19 was declared a pandemic, the government's response had been highly reactive and focused initially on minimizing the novel coronavirus’ impact on the economy. For instance, three of the four pillars of the Duterte administration's socioeconomic strategy against COVID-19 (see e.g. Department of Finance, n.d.) were all towards providing short-term financial or monetary support to facilitate economic recovery. Building public health resilience as a long-run priority was never on the agenda and state officials reportedly even downplayed the threat of the virus ( Dancel, 2020 ). The IATF provided operational command to the government's pandemic response but a coordination problem mired these efforts. Some local governments had to be more resourceful and took the initiative to secure vaccine doses instead of waiting for the national government to finalize agreements with international vaccine suppliers ( Ranada, 2021 ). The IATF, as a government-led agency, was also criticized for its lack of appropriate pandemic experts (e.g. epidemiologists), its reliance on former military officers for leadership, and for discounting inputs from important stakeholders such as businesses ( Inquirer , 2021 ).

By March 2021, the Philippines had had the world's longest lockdown—a notoriety largely derided in the international press as testament to the government's botched pandemic response ( Madarang, 2021 ). Perhaps the government thought that by limiting people's mobility it would be able to curb the spread of the virus and make a quick rebound. But people had a different appreciation of the pandemic and held different perspectives as to which policies have the most impact. Community lockdowns dislocated people from their livelihoods, creating the very conditions the government wanted to avert. As the lockdown prolonged, citizens became weary of the existing COVID-19 response and started to demand alternatives that would ease economic dislocations during and beyond the pandemic. Community quarantines and restricted mobility soon shifted public discourse on government policy from economic safety nets to the benefits of mass inoculation. On February 28, 2021, the Philippines received its first COVID-19 vaccines—the last among ASEAN countries. The government officially began its vaccine rollout on March 1, 2021, starting with medical frontliners.

Data, variables, and analytical approach

Political texts are known to be vectors of policy positions ( Laver and Garry, 2000 ). They also serve as a rich source of policy narratives which have played a key role in effective COVID-19 responses by creating opportunities for policy learning ( Mintrom and O’Connor, 2020 ).

To gauge the Philippine government's policy position on COVID-19, we compiled a dataset consisting of a corpus of 16,281 press releases on the novel coronavirus posted online by the PNA between January 30, 2020 and April 15, 2021. Since the corpus consists of the government's own press releases, it is not expected to be disinterested or neutral. As many of the press releases are likely propaganda, their selective presentation of government programs may be more towards reinforcing personality politics in the Philippines than anything else. However, as is typical in studies of this type, our interest is precisely to read the government's policy position from a corpus consisting of its own statements. This is consistent with studies that analyze political texts from unilateral sources such as party manifestos ( Eder et al., 2017 ), party elite interviews ( Ecker et al., 2022 ), and public pronouncements or speeches by key political actors such as chief executives ( Kaufman, 2020 ; Panao and Pernia, 2022 ).

The PNA (https:// www.pna.gov.ph ) is a web-based newswire service of the Philippine government, supervised by the News and Information Bureau (NIB) of the Presidential Communications Operations Office (PCOO), and is responsible for disseminating relevant newspaper articles to local and international news agencies. The data coverage begins with January 30 as this was the date of the first reported case of the novel coronavirus in the Philippines ( Edrada et al., 2020 ). However, data-wise, the earliest PNA article on COVID-19 appeared only on February 15, 2021. We then derived topic models using Latent Dirichlet Allocation (LDA), a semi-supervised probabilistic approach of finding latent or hidden topics in a collection of documents by going through the distribution of co-occurring words or vocabulary ( Blei and Jordan, 2004 ; Blei and Lafferty, 2007 ), and implemented them through the R-based application Quanteda ( Benoit et al., 2018 ).

This procedure produced 10 topics. However, only seven of these exhibited thematic coherence. The topics contained words associated with the following: the economy, vaccination, testing, security, financial aid, hospitalization, and tourism. The procedure allows for the computation of a topic score (a value between 0 and 1) which may be construed broadly as the percentage by which a topic or theme characterizes a particular document. From this, we computed a mean topic score for each news date and constructed a day-to-day series, since COVID-19 updates occur on a daily basis. We operationalize the government's policy shift as the difference between the average daily scores for the economy and vaccination, respectively.

However, politicians and bureaucrats do not have a monopoly of policy formulation. We gauge citizen interest by examining the magnitude and pattern by which Filipinos have queried the COVID-19 pandemic on the internet. The big data platform Google Trends was utilized to construct a series of daily COVID-19-related searches for the Philippines categorized into the following search topics: economy (“economy,” “recession,” “unemployment,” “Philippine economy, “beneficiary,” “social amelioration program”), vaccination (“vaccine,” “COVID-19 vaccine,” “Astrazeneca,” “Pfizer,” “Moderna,” “Sinovac”), symptoms (“COVID-19 sign,” “COVID-19 symptom,” “asymptomatic”), and lockdown (“lockdown,” “community quarantine”). Although the categories are subjective, the search keywords are not arbitrary. Words such as unemployment, recession, and social amelioration, for instance, are all related search terms that trended with economy as a search topic. COVID-19 vaccine brands, particularly AstraZeneca, Pfizer, Moderna, and Sinovac, also figured prominently as popular search topics when people keyed the term “COVID-19 vaccine.” These are the four brands officially administered to the Filipino public as part of the government's inoculation effort at the time of data collection.

In recent years, online political discourse has come to be accepted as an approximation or surrogate of public opinion comparable to social surveys ( Caldarelli et al., 2014 ; Kalampokis et al., 2013 ; Kwak and Cho, 2018 ; O’Leary, 2015 ). Aside from Twitter, Google Trends also figures in the literature as a big data alternative for gauging public opinion and for analyzing the way by which consumers seek information ( Jun et al., 2018 ). Kwak and Cho (2018) believe that Google Trends reflects more genuine thoughts because it is not shared by other social media users and is less susceptible to the bandwagon effect and social desirability bias. In practice, Google Trends is also relatively easier to use.

In the politics and policy literature, Google Trends has figured as a measure of issue salience ( Dube and Kaplan, 2012 ; Graefe et al., 2014 ; Reilly et al., 2012 ) as well as public attention to issues ( Ciuk and Yost, 2016 ; Weeks and Southwell, 2010 ). It has been used to study energy policy ( Oltra, 2011 ), public interest on space exploration ( Whitman Cobb, 2015 ), public interest on biodiversity ( Troumbis, 2017 ), the impact of local health restriction on abortion ( Reis and Brownstein, 2010 ), and the impact of global public health on health-seeking behavior ( Havelka et al., 2020 ), and even to predict presidential elections ( Prado-Román et al., 2021 ) and construct an index of racial prejudice ( Stephens-Davidowitz, 2014 ).

We clarify that resort to search trends is our attempt at approximating public opinion. By search trend, we refer specifically to search interest—that is, what Filipinos search for in real time as events unfold—and not citizens’ news consumption. A survey conducted in 2021 by Pulse Asia indicates that about six in 10 Filipinos use the internet and also about six in 10 log in more than once a day (Gonzales, 2021a). Admittedly, search interest is a crude measure, considering that the same survey also indicates that television remains the top news source for Filipinos, especially on politics and government. Only 48 percent of Filipinos rely on the internet for news, of which 44 percent say they get their news from Facebook (Gonzales, 2021b). This is a limitation we acknowledge in this article.

We construe the aforementioned COVID-19 search trends as encompassing the Filipino public's concern or interest in COVID-19-related issues. We hypothesize that in the framing of its COVID-19 policy, the government's focus on social amelioration increases as citizens’ interest in economic conditions increases, but only up to a point. As citizen's interest in economic conditions heightens further, the focus on social amelioration diminishes as the government shifts its emphasis on vaccination to convince the public to have themselves inoculated.

We begin with a descriptive and visual examination of the data and its component variables. A logistic regression entails modeling the probability of the presence or existence of a particular event or class. In this case, our interest is in the probability of COVID-19-related vaccination getting more attention than social amelioration as a thematic focus of government policy narrative. An event is construed operationally as one in which vaccination as a topic model in the press release corpus exceeds social amelioration as a topic share for a given date. The graph in Figure 2 gives an informal comparison between vaccination and social amelioration as topics in the aggregated press releases issued between February 2020 and May 2021. To facilitate visual assessment, the values are normalized for both variables of interest.

COVID-19 vaccination and social amelioration as topic models. Note: Values are normalized to facilitate visual comparison.

As the graph suggests, the government's economic response to COVID-19 has been considerably oriented towards mitigating the social cost of the pandemic. However, the trend appears to dissipate and over time the government's policy position seems to shift towards mass vaccination. Interest in mass vaccination, on the other hand, had a steadily trending increase that became more conspicuous sometime in the middle of January. The vertical line corresponding to February 28, 2021 indicates the date when the Philippines officially received its first delivery of COVID-19 vaccines. The press touted the event as kick-starting the government's mass inoculation campaign ( Tomacruz, 2020 ). The highest observed search interest was on March 1, 2021. Meanwhile, the highest reported search interest on social amelioration was on April 27, 2020. The variable pertaining to the government's shifting policy narratives takes only two values (1 and 0). In the dataset, more than a third (36 percent) of the observations refer to instances in which vaccination received more policy attention than social amelioration. Table 1 gives a descriptive summary of the variables.

Descriptive statistics.

In the models, a day lag is used for all independent variables to ensure causality.

Table 2 summarizes the estimates for three logistic regression models gauging the effect of citizens’ concern about the economy on the government's COVID-19 policy position. Model 1 is an unrestricted model containing both linear and squared specification for query interest on the economy, while controlling for other COVID-19-related search topics, as well as the number of daily confirmed cases and deaths. Model 2 specifies interest in the economy as having only a linear relationship but likewise includes the previously identified control variables. The hypothesis suggests that citizens’ growing concern about the economy would, at some point, cause the government's policy focus to pivot from social amelioration to mass vaccination. It is not enough for this assumption to have a theoretical basis, however; the data must also provide structural support. Hence, following Cohen (2013) , we ran Box-Tidwell ( Box and Tidwell, 1962 ) transformations for the models to check whether our data support a curvilinear conjecture. Box-Tidwell regressions for the first two models did not converge. Meanwhile, the Box-Tidwell transformation for a more parsimonious specification seems to suggest a curvilinear relationship for interest in the economy, interest in vaccines, and new confirmed COVID-19 cases.

Summary of logistic regression estimates.

Standard errors in parentheses. * p  < 0.05, ** p  < 0.01, *** p  < 0.001.

To examine whether the squared terms have explanatory power even with streamlined parameters, we conducted link tests for model adequacy ( Pregibon, 1980 ; Tukey, 1949 ). Similarly, the link tests seem to prefer the parsimonious parameters in Models 3 and 4. Model 3 includes squared terms for the three variables assumed to be curvilinear but vaccine interest in this specification does not appear to have a significant effect. Model 4, which restricts the assumption of a curvilinear relationship to interest in the economy and new confirmed cases, also suggests that the relationship between interest in vaccines and a shifting policy narrative is linear.

Both Models 3 and 4 support the hypothesis that citizens’ pocketbook assessments of the economy have both short-and long-term effects on the government's policy response. The curvilinear relationship suggests that as Filipinos anxiously inquire about their livelihood and the economy amidst the COVID-19 pandemic, the government responds by providing social safety nets as an initial response. But as such interest in their economic condition heightens due to prolonged economic disruptions, the government is constrained to shift its policy focus towards wide-scale inoculation. For a more tangible notion of how much citizens’ pocketbook assessment of the economy shapes government policy, we examine adjusted predicted probabilities at various magnitudes, while all other variables are set at their means. To facilitate interpretation, the graph in Figure 3 illustrates the relationship visually.

Citizen's search interest in the economy and government's policy frame.

In periods in which citizens’ apprehension about the economy is still manageable, policy attention on social amelioration is also low and government has room to explore other policy options such as mass vaccination in its narrative. As people become more anxious about worsening economic dislocations, however, policy attention to social amelioration also increases in an attempt to pander to citizens’ demand. As economic anxiety heightens further, policy attention shifts back to mass vaccination, possibly as a long-term response. In Model 4, the turning point is when interest in the economy is at 2.8. The mean of the economic interest index is 1.7. About 20 percent of the observations are equal or above the tipping point, suggesting that the curvilinear specification is justified.

Model 4 also suggests that there is only a linear relationship between citizens’ interest in vaccines and policy attention. The probability of the government highlighting mass inoculation in its policy narrative increases with the public's growing interest in vaccines. Under a linear specification, this relationship is straightforward and statistically very significant. Figure 4 depicts this relationship visually.

Citizens’ search interest in vaccines and government's policy frame.

As with an interest in economic conditions, the number of daily confirmed new COVID-19 cases has a curvilinear relationship with attention to vaccines in the government's policy narrative. Although no specific hypothesis was posited for this variable, the result is intuitive and consistent with the article's overall theoretical conjecture. Based on the findings, the government panders to citizens’ demand for ameliorative socioeconomic interventions as daily COVID-19 cases increase, but only up to a point. Figure 5 shows that as the number of daily infections increases, policy attention shifts to vaccines in the government's policy narrative.

Daily new COVID-19 cases and policy frame.

In this article, we show that the Philippine government's framing of its response to the pandemic has vacillated between easing socioeconomic dislocations through temporary social amelioration and convincing the public to get inoculated. As citizens become interested in the economic implications of the pandemic, the government responds by highlighting social amelioration in its policy narratives. However, as citizens’ search interest increases with mounting economic dislocations, the government is constrained to redirect the focus of its policy narratives towards mass vaccination.

In the media, this approach was heavily criticized for slowing down the rollout of vaccines and aggravating the economic stagnation brought by mobility curbs at the height of the pandemic ( Gonzales, 2021 ). Securing and delivering vaccines to ensure immediate access to the most vulnerable people has long been a recognized public health policy ( Carroll et al., 2015 ; Hasan et al., 2021 ), and the Philippines may have acted a little late in this regard. Some in the Filipino medical community blame delayed procurement for the slow pandemic recovery ( Macaraeg, 2021 ), an indication of mismanagement according to some political coalitions ( Ramos, 2021 ). Studies observed that when the second wave of infection hit the Philippines in 2021, the government was so preoccupied with reallocating resources to COVID-19 that it did not take long for the public health system to become overwhelmed ( Uy et al., 2022 ). By April 2021, rising numbers of cases pushed many facilities to critical capacity, so much so that hospitals turning away both COVID-19 and non-COVID-19 patients had become commonplace ( Morales and Lema, 2021 ).

Arguably, the patchy state of the healthcare system tells a lot about the quality of the government response. It may be contended further that the government's semblance of responsiveness was all part of performance politics in anticipation of the 2022 elections. These are valid claims worthy of further scholarly introspection. Their elaboration, however, is beyond the scope of this article. What seems to be certain is that, like its counterparts elsewhere, the Philippine government was motivated and constrained by whatever capacity and opportunity were available in the creation of its pandemic response ( Capano et al., 2020 ; Rudan, 2021 ). If COVID-19 is straining the public health system of wealthy countries, conditions are worse in developing countries grappling with social protection and health financing ( Shadmi et al., 2020 ). Even before the pandemic, the Philippine healthcare system was already ill-prepared with its poorly funded public hospitals and inadequate social health insurance ( Obermann et al., 2006 ; Querri et al., 2018 ). Current missteps and poor strategy amidst the pandemic only magnified what is already obvious.

The government initially anchored its COVID-19 response on a social amelioration program intended to minimize the economic cost of business suspensions and lockdowns. Operating on the assumption that the pandemic will only be temporary, the government pandered to citizens’ demand for social assistance payments and the physical distribution of cash. But social assistance programming being expensive, inefficient, and susceptible to imperfect targeting ( Gerard et al., 2020 ), public demand for additional economic assistance also became a wake-up call of sorts for the government to seek a long-term public health option. Policy learning without a doubt occurred late but nonetheless this is far from the conventional populist description of seeking easy solutions or spectacularizing the crisis response. This is also consistent with prior accounts of resourced-constrained governments with fragmented political institutions opting for incremental policy changes over comprehensive reforms when faced with a health crisis ( Oliver, 2006 ).

Nevertheless, we do acknowledge methodological limitations whose exploration would no doubt provide a richer understanding of crisis policy framing in the Philippines. Television, for instance, remains the top news source for Filipinos and may provide another dimension to Filipinos’ information-seeking behavior if data can be derived meaningfully. Filipinos’ social media behavior also suggests a promising platform for analyzing the link between public opinion and public policy, subject to parameters that will minimize the noise and bias in generated data ( Olteanu et al., 2019 ).

Our findings have a number of implications. While regimes matter in dissecting pandemic responses, there is a lot to learn from citizens’ emotions and their potential to catalyze desirable policy outcomes. Also, in developing countries with patchy healthcare systems, the difficulty balancing between economic and public health priorities could just as easily be a function of structural inadequacy as it is of administrative inefficiency. Finally, in future pandemic response it may be worthwhile for governments to keep in mind that policy learning is meaningless unless decision makers act with coherence, foresight, and a sense of immediacy.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant for research on COVID19 in the Philippines from the Institute of Mathematics, College of Science, University of the Philippines Diliman.

ORCID iD: Rogelio Alicor L Panao https://orcid.org/0000-0002-9834-1318

Contributor Information

Rogelio Alicor L Panao, University of the Philippines Diliman, Philippines.

Ranjit Singh Rye, University of the Philippines Diliman, Philippines.

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Coronavirus Disease 2019

Filipino responses to covid-19, research documents filipino panic responses to the global pandemic..

Posted April 30, 2020 | Reviewed by Kaja Perina

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By Georgina Fairbrother

A recent study explored panic responses to COVID-19 in the Philippines. COVID-19 has been declared a global pandemic and has caused mass lockdowns and closures across the globe. An angle relatively unexplored amidst this global pandemic is the impact of COVID-19 on mental health. The survey conducted was a mixed-method study that gathered qualitative and quantitative data in order to better explore the different dimensions of panic responses.

The survey was conducted through convenience sampling by online forms due to government-mandated limitations of social contact and urgency. The online survey ran for three days and gathered 538 responses. The average age of a survey participant was 23.82, with participants ranging in ages from 13-67. 47% of those who completed the survey were working, 45.4% were students and 7.6% were not working. Of those who completed the survey, 1.3% had witnessed direct exposure to a COVID-19 patient, while 26% had witnessed exposure within their community, and 72.7% had not been exposed.

For purposes of the survey, the Health Anxiety Inventory (HAI) Short Week was adapted in order to test illness anxiety on COVID-19 amongst Filipinos. The HAI had four main sections used in this survey: 1) Symptoms of health anxiety (hypochondriasis), 2) Attitudes towards how awful it would be to develop COVID-19, 3) Avoidance, and 4) Reassurance. Responses to questions answered within these areas were scored on a 0-3 basis, compromising the quantitative portion of the study. To complete the qualitative section of the survey three open-ended questions were used. The open-ended questions used for qualitative purposes in this survey were:

“1. What came to your mind when you knew the existence of COVID-19? 2. How do you feel when you know the existence of COVID-19? 3. What actions have you done with the knowledge of existence of COVID-19?”

Upon completion of the survey, researchers were able to analyze data in regard to five different areas. First, researchers discovered that it was very evident that respondents were experiencing moderate illness anxiety in all four aspects listed by HAI. Secondly, by comparing locations, researchers also discovered that respondents residing in Metro Manilla exhibited less avoidance behavior compared to respondents residing outside Metro Manilla. While there is no definitive reason for this result, speculation looms around education , awareness, and proximity to COVID-19 cases. Thirdly, researchers looked at occupation, but determined illness anxiety was present regardless of occupation. Fourthly, researchers determined that respondents who had been in direct contact with those having COVID-19 were more likely to exhibit symptoms of hypochondriasis compared to respondents who had not witnessed or contacted anyone with COVID-19.

The fifth area that researchers explored upon completion of this survey was that of feeling, thinking, and behavior in response to COVID-19. Nineteen different themes were ranked by 100 experts based on their positivity and negativity. The themes included items such as the following: Health Consciousness, Optimism , Cautiousness, Protection, Compliance, Composure, Information Dissemination, Worry on self/family/others, Relating to Past Pandemics, Anxiety, Government Blaming, Shock, Transmission of Virus, Fear, Sadness, Paranoia , Nihilism, Annihilation, and Indifference. Upon completion of the survey, the highest-scoring themes amongst respondents included Fear, Social Distancing, Health Consciousness, and Information Dissemination. Meanwhile, the lowest-scoring themes included Indifference and Nihilism.

Overall, COVID-19 has become a global pandemic that is continuing to move and spread across the world. In the aftermath of this pandemic, it will be interesting to compare the panic responses of different countries. The Philippines approaches this study from a more socially collectivist perspective. With that being said, it was reported that the Philippines leaned towards more individualistic tendencies in times of fear. Another area to look deeper into would include how panic responses change from the initial shock of COVID-19 to lockdown phases to re-emergence phases.

Georgina Fairbrother is a current master’s student in the Humanitarian and Disaster Leadership program at Wheaton College. Prior to her master’s degree, she received a bachelor’s degree in Global Security and Intelligence studies from Embry-Riddle Aeronautical University.

Nicomedes, C. J., & Avila, R. (2020). An Analysis on the Panic of Filipinos During COVID-19 Pandemic in the Philippines. https://doi.org/10.13140/RG.2.2.17355.54565

Jamie Aten , Ph.D. , is the founder and executive director of the Humanitarian Disaster Institute at Wheaton College.

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eTable 1. Summary of covariate definitions

eTable 2. Summary of cohort characteristics

eTable 3. Medical history of people in the pre-vaccine availability, vaccinated and unvaccinated cohorts

eTable 4. Mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, by prior history of the outcome

eTable 5. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts

eTable 6. Maximally adjusted hazard ratios and 95% CIs for mental illness events following hospitalised COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts

eTable 7. Maximally adjusted hazard ratios and 95% Cis for mental illness events following non-hospitalised COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts

eTable 8. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, in people with no prior history of the outcome

eTable 9. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, in people with prior history of the outcome, more than six months ago

eTable 10. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, in people with prior history of the outcome, within six months

eTable 11. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, in people with history of COVID-19

eTable 12. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for age group 18-39

eTable 13. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for age group 40-59

eTable 14. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for age group 60-79

eTable 15. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for age group 80-110

eTable 16. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for women

eTable 17. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for men

eTable 18. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for White ethnicity

eTable 19. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for South Asian ethnicity

eTable 20. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for Black ethnicity

eTable 21. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for Other ethnicity

eTable 22. Maximally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts for Mixed ethnicity

eTable 23. Excess events per 100,000 people at 28 weeks post-COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts

eFigure 1. COVID-19 cases over time

eFigure 2. Diagram showing cohort construction

eFigure 3. Venn Diagram showing cohort overlap

eFigure 4. Maximally and minimally adjusted hazard ratios and 95% CIs for mental illness events following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts. Events on the day of COVID-19 diagnosis (day 0) were excluded

eFigure 5. Maximally adjusted hazard ratios and 95% CIs for depression and serious mental illness following diagnosis of COVID-19 in the vaccinated and unvaccinated cohorts, by history of COVID-19. Events on the day of COVID-19 diagnosis (day 0) were excluded

eFigure 6. Maximally adjusted hazard ratios and 95% CIs for depression and serious mental illness following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, by age group. Events on the day of COVID-19 diagnosis (day 0) were excluded

eFigure 7. Maximally adjusted hazard ratios and 95% CIs for depression and serious mental illness following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, by sex. Events on the day of COVID-19 diagnosis (day 0) were excluded

eFigure 8. Maximally adjusted hazard ratios and 95% CIs for depression and serious mental illness following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts, by ethnicity. Events on the day of COVID-19 diagnosis (day 0) were excluded

eFigure 9. Absolute excess risk up to 28 weeks for depression and serious mental illness following diagnosis of COVID-19 in the pre-vaccine availability, vaccinated and unvaccinated cohorts

Members of the Longitudinal Health and Wellbeing COVID-19 National Core Study

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Walker VM , Patalay P , Cuitun Coronado JI, et al. COVID-19 and Mental Illnesses in Vaccinated and Unvaccinated People. JAMA Psychiatry. Published online August 21, 2024. doi:10.1001/jamapsychiatry.2024.2339

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COVID-19 and Mental Illnesses in Vaccinated and Unvaccinated People

• 1 Population Health Sciences, University of Bristol, Bristol, United Kingdom
• 2 Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
• 3 Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
• 4 Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
• 5 Centre for Longitudinal Studies, University College London, London, United Kingdom
• 6 National Institute for Health and Care Research, Bristol Biomedical Research Centre, Bristol, United Kingdom
• 7 Health Data Research UK South-West, Bristol, United Kingdom
• 8 Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
• 9 The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
• 10 Department of Twin Research and Genetic Epidemiology, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
• 11 School of Psychology, University of Sussex, Falmer, United Kingdom
• 12 British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
• 13 Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, United Kingdom
• 14 Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, United Kingdom
• 15 The National Institute for Health and Care Research Applied Research Collaboration West at University Hospitals Bristol and Weston, United Kingdom
• 16 British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
• 17 National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
• 18 Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
• 19 Cambridge Centre of Artificial Intelligence in Medicine, Cambridge, United Kingdom
• 20 Swansea University Medical School, University of Swansea, Swansea, United Kingdom

Question   What are the associations between mental illnesses and diagnosed COVID-19 by vaccination status in patients hospitalized for COVID-19 and the general population?

Findings   In this cohort study, depression, serious mental illness, general anxiety, posttraumatic stress disorder, eating disorders, addiction, self-harm, and suicide were elevated during weeks 1 through 4 after COVID-19 diagnosis compared with before or without COVID-19. Incidence was lower in people who were vaccinated when they had COVID-19 and incidence was higher, and persisted longer, after hospitalization for COVID-19.

Meaning   The findings support recommendation of COVID-19 vaccination in the general population and particularly among those with mental illness, who may be at higher risk of both SARS-CoV-2 infection and adverse outcomes following COVID-19.

Importance   Associations have been found between COVID-19 and subsequent mental illness in both hospital- and population-based studies. However, evidence regarding which mental illnesses are associated with COVID-19 by vaccination status in these populations is limited.

Objective   To determine which mental illnesses are associated with diagnosed COVID-19 by vaccination status in both hospitalized patients and the general population.

Design, Setting, and Participants   This study was conducted in 3 cohorts, 1 before vaccine availability followed during the wild-type/Alpha variant eras (January 2020-June 2021) and 2 (vaccinated and unvaccinated) during the Delta variant era (June-December 2021). With National Health Service England approval, OpenSAFELY-TPP was used to access linked data from 24 million people registered with general practices in England using TPP SystmOne. People registered with a GP in England for at least 6 months and alive with known age between 18 and 110 years, sex, deprivation index information, and region at baseline were included. People were excluded if they had COVID-19 before baseline. Data were analyzed from July 2022 to June 2024.

Exposure   Confirmed COVID-19 diagnosis recorded in primary care secondary care, testing data, or the death registry.

Main Outcomes and Measures   Adjusted hazard ratios (aHRs) comparing the incidence of mental illnesses after diagnosis of COVID-19 with the incidence before or without COVID-19 for depression, serious mental illness, general anxiety, posttraumatic stress disorder, eating disorders, addiction, self-harm, and suicide.

Results   The largest cohort, the pre–vaccine availability cohort, included 18 648 606 people (9 363 710 [50.2%] female and 9 284 896 [49.8%] male) with a median (IQR) age of 49 (34-64) years. The vaccinated cohort included 14 035 286 individuals (7 308 556 [52.1%] female and 6 726 730 [47.9%] male) with a median (IQR) age of 53 (38-67) years. The unvaccinated cohort included 3 242 215 individuals (1 363 401 [42.1%] female and 1 878 814 [57.9%] male) with a median (IQR) age of 35 (27-46) years. Incidence of most outcomes was elevated during weeks 1 through 4 after COVID-19 diagnosis, compared with before or without COVID-19, in each cohort. Incidence of mental illnesses was lower in the vaccinated cohort compared with the pre–vaccine availability and unvaccinated cohorts: aHRs for depression and serious mental illness during weeks 1 through 4 after COVID-19 were 1.93 (95% CI, 1.88-1.98) and 1.49 (95% CI, 1.41-1.57) in the pre–vaccine availability cohort and 1.79 (95% CI, 1.68-1.90) and 1.45 (95% CI, 1.27-1.65) in the unvaccinated cohort compared with 1.16 (95% CI, 1.12-1.20) and 0.91 (95% CI, 0.85-0.98) in the vaccinated cohort. Elevation in incidence was higher and persisted longer after hospitalization for COVID-19.

Conclusions and Relevance   In this study, incidence of mental illnesses was elevated for up to a year following severe COVID-19 in unvaccinated people. These findings suggest that vaccination may mitigate the adverse effects of COVID-19 on mental health.

SARS-CoV-2 infection, and consequent COVID-19, are associated with subsequent mental illnesses in both hospital- and population-based studies, 1 , 2 including both common mental health difficulties, such as anxiety and depressive symptoms, 3 and serious mental illness, including psychotic disorders. 4 Potential mechanisms include physiological pathways, such as inflammation and microvascular changes, and psychosocial effects, such as anxiety about the potential outcomes of COVID-19, including post–COVID-19 condition. Previous studies have identified associations of COVID-19 with mental illnesses in both hospitalized patients 5 , 6 and the general population. 1 , 7 , 8 Differentiating between hospitalized patients and the general population may provide insights into the implications of COVID-19 severity for subsequent mental illnesses. 9

Rapid rollout of COVID-19 vaccination was a crucial component of the public health response. Although the impacts of vaccination in preventing and reducing the severity of COVID-19 are well established, 10 , 11 there is limited evidence regarding the implications of vaccination for other adverse outcomes of COVID-19, including mental illnesses. We did not identify any studies investigating differences in mental illnesses following COVID-19 by vaccination status. Furthermore, rates of SARS-CoV-2 infection, vaccination, and disease severity may differ by sociodemographic and health factors, 12 - 16 so mental health outcomes may also vary between subgroups.

Using electronic health record data from more than 18 million people, we examined associations of diagnosed COVID-19 with subsequent mental illnesses prior to vaccine availability and for unvaccinated and vaccinated people after vaccination became available. We compared rates of mental illnesses after COVID-19 with rates before or without COVID-19. We also examined associations in subgroups defined by COVID-19 severity, age, sex, ethnicity, prior mental illness, and prior COVID-19. Ethnicity data were reported because disparities in COVID-19 outcomes by ethnic group have been reported. 17 Follow-up of those diagnosed with COVID-19 during the first year of the pandemic was for up to 2 years postdiagnosis.

Our study used OpenSAFELY-TPP, which provides secure, privacy-protecting access to linked data from 24 million people registered with general practices (GPs) in England using TPP SystmOne software. These data include primary care data linked via pseudonymized National Health Service number to the Secondary Uses Service secondary care data, the Office of National Statistics Death Registry, the Second Generation Surveillance System COVID-19 testing data, and the Index of Multiple Deprivation. COVID-19 vaccination records (National Immunisation Management System) are available within TPP primary care data. In March 2020, the Secretary of State for Health and Social Care used powers under the UK Health Service (Control of Patient Information) Regulations 2002 to require organizations to process confidential patient information for the purposes of protecting public health, providing health care services to the public, and monitoring and managing the COVID-19 outbreak and incidents of exposure; this sets aside the requirement for patient consent. Ethics approval for this study was obtained from the Health Research Authority and the University of Bristol’s Faculty of Health Sciences Ethics Committee. This study is reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We present main findings for depression and serious mental illness (composite of schizophrenia, schizoaffective disorder, bipolar disorder, and psychotic depression). We also examined general anxiety disorders, posttraumatic stress disorder, eating disorders, addiction, self-harm, and suicide, which are presented in eTables 5-7 and eFigure 4 in Supplement 1 . Each outcome was defined using the earliest of a Systematized Nomenclature of Medicine–Clinical Terms code (a structured clinical vocabulary to record clinical events) in primary care; start of a hospital admission with an International Statistical Classification of Diseases and Related Health Problems , Tenth Revision ( ICD-10 ) code in any position; or death with an ICD-10 code as the primary or underlying cause. We considered the first record only as individuals were removed from the cohort censored at this point. Codes indicating a relevant mental illness prior to the study period were captured by history covariates. Individuals with multiple mental illnesses were included in all relevant analyses with other mental illnesses captured by history covariates.

Date of COVID-19 was defined as the first of confirmed diagnosis recorded in primary care, positive SARS-COV-2 polymerase chain reaction or antigen test recorded in the Second Generation Surveillance System, start of a hospital admission with a confirmed diagnosis in any position, or death with SARS-COV-2 infection listed as the primary or underlying cause. People with a hospital admission record including a confirmed diagnosis in the primary position within 28 days of first COVID-19 were defined as having had hospitalization for COVID-19. All other COVID-19 diagnoses were defined as not hospitalized for COVID-19. The term confirmed diagnosis refers to diagnoses where the virus was identified by laboratory testing, irrespective of clinical symptom severity. We defined the date of confirmed COVID-19 diagnosis using the first record only, although additional secondary care information was used to classify COVID-19 as either leading to hospitalization or not. We did not consider multiple COVID-19 diagnoses within the study period as there is no agreed-on definition for COVID-19 reinfection using routinely collected data.

Covariates identified as potential confounders included age, sex, ethnicity, deprivation (using the Index of Multiple Deprivation—the official measure of relative deprivation for small areas in England defined by 7 domains, including income and barriers to housing and services), smoking status, care home residence, health care work, GP-patient interactions in 2019, and binary indicators for comorbidities (eTable 1 in Supplement 1 ).

Three cohorts were defined (eTable 2, eFigure 1 in Supplement 1 ). The pre–vaccine availability cohort was followed up from January 1, 2020 (baseline), until the earliest of December 14, 2021, 18 date of outcome, date of deregistration, or date of death. Exposure was defined as recorded COVID-19 between baseline and the earliest date of eligibility for COVID-19 vaccination, date of first vaccination, and June 18, 2021 (when all adults became eligible for vaccination). Follow-up in the vaccinated cohort started at the later of June 1, 2021 (baseline), or 2 weeks after a second COVID-19 vaccination and ended at the earliest of December 14, 2021, date of outcome, date of deregistration, or date of death. The unvaccinated cohort had not received a COVID-19 vaccine by 12 weeks after they became eligible for vaccination. Follow-up started at the later of June 1, 2021 (baseline), or 12 weeks after vaccination eligibility and ended at the earliest of December 14, 2021, date of outcome, date of deregistration, or date of death. Eligibility criteria for each cohort are provided in the eMethods in Supplement 1 . Individuals could potentially be followed up in all 3 cohorts but most often they were in the pre–vaccine availability cohort and either the vaccinated or unvaccinated cohort. The cohort definitions imply that diagnoses of mental illnesses after eligibility for vaccination in people who were not diagnosed with COVID-19 could be included in the comparison incidence rate calculations in both the pre–vaccine availability cohort and at most 1 of the vaccinated and unvaccinated cohorts. However, each COVID-19 diagnosis could be recorded in only 1 of the 3 cohorts, and therefore, each post–COVID-19 mental illness outcome could be included in only 1 of the 3 cohorts. Therefore, findings from each cohort are close to being statistically independent.

For each cohort, baseline characteristics were described, and numbers of outcome events, person-years of follow-up, and incidence rates (per 100 000 person-years) before and after all COVID-19 diagnoses, those leading to hospitalization, and those not leading to hospitalization were tabulated. Time to first event was analyzed for each outcome. Cox models were fitted with calendar time scale using the cohort-specific baseline as the origin. Hazard ratios (HRs) for follow-up after vs before or without COVID-19 were estimated, splitting follow-up into the day of COVID-19 diagnosis (day 0), the remainder of 1 to 4 weeks, and 5 to 28 weeks after COVID-19 for all cohorts and additionally 29 to 52 and 53 to 102 weeks after COVID-19 for the pre–vaccine availability cohort. For computational efficiency, we used sampling for analyses containing more than 4 000 000 people; we included all people with the outcome event, all people with the exposure (COVID-19 diagnosis), and a 10% random sample (for general anxiety, depression, and serious mental illness) or 20% random sample (for all other outcomes) of people who were not diagnosed with COVID-19 and in whom the outcome event was not recorded. We used inverse probability weights to adjust for the sampling and derived confidence intervals using robust standard errors. For each outcome and cohort, we estimated age- and sex-adjusted and maximally adjusted HRs including all covariates. Restricted cubic splines were used to account for age unless otherwise specified. All models were stratified by region to construct risk sets within region, accounting for between-region variation in the baseline hazard.

Subgroup analyses according to history of the outcome, age group, sex, ethnicity, and COVID-19 history were conducted for depression and serious mental illness. We calculated absolute excess risk 28 weeks after COVID-19, including outcomes recorded on the day of COVID-19 diagnosis (day 0) and weighted by the proportion of people in age and sex strata in the pre–vaccine availability cohort (eMethods in Supplement 1 ).

The study was conducted in Python version 3.8.10 (Python Software Foundation), R version 4.0.2 (R Foundation), and Stata/MP version 16.1 (StataCorp) according to a prespecified protocol. Our protocol, analysis code, and code lists are available. 19 All outputs were subjected to OpenSAFELY disclosure controls, including rounding where appropriate. 20 Data were analyzed from July 2022 to June 2024.

The pre–vaccine availability cohort included 18 648 606 people (9 363 710 [50.2%] female and 9 284 896 [49.8%] male; median [IQR] age, 49 [34-64] years) 1 012 335 of whom had COVID-19 ( Table 1 ; eFigure 2 in the Supplement ). The cohort included 1 191 793 (6.4%) Black individuals; 217 132 (1.2%) South Asian individuals; 14 865 866 (79.7%) White individuals; 423 111 individuals (2.3%) of mixed ethnicity; and 400 437 of other ethnicities (2.1%), consolidated for disclosure control; and 1 550 267 individuals (8.3%) for whom ethnicity data were missing. The vaccinated cohort included 14 035 286 individuals (median [IQR] age, 53 [38-67] years; 7 308 556 [52.1%] female and 6 726 730 [47.9%] male; 789 476 [5.6%] Black, 128 514 [0.9%] South Asian, 11 752 297 [83.7%] White, 237 383 [1.7%] mixed, 789 476 [5.6%] other, and 910 299 [6.5%] missing), 866 469 of whom had COVID-19. The unvaccinated cohort included 3 242 215 people (median [IQR] age, 35 [27-46] years; 1 363 401 [42.1%] female and 1 878 814 [57.9%] male; 325 199 [10%] Black, 81 017 [2.5%] South Asian, 2 025 492 [62.5%] White, 190 874 [5.9%] mixed, 173 014 [5.3%] other, 446 619 [13.8%] missing), 149 745 of whom had COVID-19. Differences in demographic characteristics between these cohorts reflect factors associated with COVID-19 vaccine uptake. 21 eTable 3 in Supplement 1 summarizes participants’ medical history by cohort. Rates of COVID-19 differed by cohort ( Table 1 ). Higher rates were observed in cohorts followed up when the Delta variant was dominant (vaccinated: 915 per 100 000 person years and unvaccinated: 1274 per 100 000 person years) than when the wild-type or Alpha variants were dominant (pre–vaccine availability: 308 per 100 000 person years). Of the 18 648 606 individuals in the pre–vaccine availability cohort, 12 969 492 (69.5%) were subsequently followed up in the vaccinated cohort and 2 843 514 (15.2%) were subsequently followed up in the unvaccinated cohort (eFigure 3 in Supplement 1 ). Of 17 121 348 individuals included in either the unvaccinated or vaccinated cohort, 156 144 (0.91%) were included in both.

The incidence of mental illnesses was higher after COVID-19 than before or without COVID-19 ( Table 2 ). Between-cohort differences in the incidence of mental illnesses in the absence of COVID-19 likely reflect both demographic differences and changes in diagnostic practices and access to health care during the pandemic. The highest incidence rates were after hospitalization for COVID-19. Depression was the most common outcome with 1 329 270, 352 944, and 57 810 diagnoses in the pre–vaccine availability, vaccinated, and unvaccinated cohorts, respectively. The corresponding diagnoses of serious mental illness were 397 368, 88 500, and 18 726. Separating individuals by their history of the outcome, incidence of mental illnesses after COVID-19 was greater in those with than without history (eTable 4 in Supplement 1 ).

Maximally adjusted HRs (aHRs) comparing the incidence of each outcome after COVID-19 with the incidence before or without COVID-19 did not differ substantially from the age- and sex-adjusted HRs (eFigure 4 in Supplement 1 ). The incidence of all outcomes was extremely high on day 0 (eTable 5 in Supplement 1 ). The incidence of most outcomes was elevated during the remainder of 1 to 4 weeks after COVID-19, compared with before or without COVID-19, in each cohort. For all figures, aHRs are plotted against the median time from date of COVID-19 diagnosis to date of outcome in each cohort.

Incidence of depression was elevated during weeks 1 through 4 after COVID-19, compared with before or without COVID-19, in the pre–vaccine availability and unvaccinated cohorts (aHR, 1.93; 95% CI, 1.88-1.98 and aHR, 1.79; 95% CI, 1.68-1.90, respectively) and, to a lesser extent, the vaccinated cohort (aHR, 1.16; 95% CI, 1.12-1.20) ( Figure 1 ; eTable 5 in Supplement 1 ). Incidence remained elevated during weeks 5 through 28 in the vaccinated and unvaccinated cohorts (aHR, 1.11; 95% CI, 1.08-1.14 and aHR, 1.28; 95% CI, 1.21-1.36, respectively) and up to weeks 53 through 102 in the pre–vaccine availability cohort (aHR, 1.17; 95% CI, 1.14-1.21). aHRs during weeks 1 through 4 were considerably higher after COVID-19 with hospitalization (pre–vaccine availability: 16.3; 95% CI, 15.6-17.0; vaccinated: 12.9; 95% CI, 12.0-14.0; unvaccinated: 15.6; 95% CI, 13.9-17.4) than without hospitalization (pre–vaccine availability: 1.22; 95% CI, 1.18-1.27; vaccinated: 0.92; 95% CI, 0.88-0.95; unvaccinated: 1.11; 95% CI, 1.02-1.20) ( Figure 1 ; eTables 6 and 7 in Supplement 1 ). In the pre–vaccine availability cohort, aHRs remained higher after COVID-19 with hospitalization than without hospitalization throughout follow-up.

Incidence of serious mental illness was elevated during weeks 1 through 4 after COVID-19, compared with before or without COVID-19, in the pre–vaccinated and unvaccinated cohorts (aHR, 1.49; 95% CI, 1.41-1.57 and aHR, 1.45; 95% CI, 1.27-1.65, respectively) ( Figure 1 ; eTable 5 in Supplement 1 ). However, incidence was lower during weeks 1 through 4 in the vaccinated cohort (aHR, 0.91; 95% CI, 0.85-0.98). Incidence remained slightly elevated during weeks 5 through 28 in the vaccinated and unvaccinated cohorts (aHR, 1.05; 95% CI, 1.00-1.11 and aHR, 1.14; 95% CI, 1.02-1.27) and up to weeks 53 through 102 in the pre–vaccine availability cohort (aHR, 1.14; 95% CI, 1.08-1.21). Incidence of serious mental illness during weeks 1 through 4 was considerably higher after COVID-19 with hospitalization (pre–vaccine availability: aHR, 9.71; 95% CI, 8.80-10.7; vaccinated: aHR, 6.52; 95% CI, 5.36-7.93; unvaccinated: aHR, 8.75; 95% CI, 7.01-10.9) than after COVID-19 without hospitalization (pre–vaccine availability: aHR, 1.05; 95% CI, 0.98-1.12; vaccinated: aHR, 0.79; 95% CI, 0.73-0.86; unvaccinated: aHR, 1.00; 95% CI, 0.85-1.17) ( Figure 1 ; eTables 6 and 7 in Supplement 1 ).

Incidence of depression was highest during weeks 1 through 4 after COVID-19, vs before or without COVID-19, for people with history of the outcome more than 6 months ago ( Figure 2 ; eTables 8-10 in Supplement 1 ). However, incidence of serious mental illness was highest during weeks 1 through 4 after COVID-19 for people with history of the outcome within 6 months for the pre–vaccine availability (aHR, 1.90; 95% CI, 1.60-2.27) and vaccinated cohorts (aHR, 1.03; 95% CI, 0.84-1.27). Incidences of depression and serious mental illness after COVID-19, vs before or without COVID-19, were similar in people with and without a history of COVID-19 (eFigure 5 and eTable 11 in Supplement 1 ). Incidence of depression during weeks 1 through 4 and 5 through 28 and for serious mental illness across all time periods were greater in the age groups 60 years and older than in the age groups 60 years and younger (eFigure 6 and eTables 12-15 in Supplement 1 ). Incidences of depression and serious mental illness were marginally higher for men than women during weeks 1 through 4 after COVID-19 (eFigure 7 and eTables 16 and 17 in Supplement 1 ). Incidences of depression and serious mental illness after COVID-19 were generally comparable between ethnic groups, when they could be estimated (eFigure 8, eTables 18-22 in Supplement 1 ).

Incidences of other mental illnesses were broadly similar to those of depression and serious mental illness, both overall ( Figure 3 , eTable 5 in Supplement 1 ) and for COVID-19 with and without hospitalization (eTables 6 and 7 in Supplement 1 ). An exception was that incidence of posttraumatic stress disorder after COVID-19 with hospitalization, vs before or without COVID-19, was higher during weeks 1 through 4 in the vaccinated cohort than the other cohorts (pre–vaccine availability: aHR, 20.1; 95% CI, 15.8-25.6; vaccinated: aHR, 27.3; 95% CI, 20.3-36.6; unvaccinated: aHR, 13.3; 95% CI, 8.00-22.2). This pattern was not present for COVID-19 without hospitalization or overall.

Estimated excess risks of depression 28 weeks after COVID-19, standardized to the age and sex distribution of the pre–vaccine availability cohort, were 1033, 451, and 1008 per 100 000 people in the pre–vaccine availability, vaccinated, and unvaccinated cohorts, respectively (eFigure 9 and eTable 23 in Supplement 1 ). The equivalent estimated excess risks of serious mental illness were 235, 53, and 209 per 100 000 people. Many of the estimated excess events occurred on the day of COVID-19 diagnosis (day 0).

In this cohort study of more than 18 million people with up to 2 years of follow-up, rates of most mental illnesses were markedly elevated during weeks 1 through 4 after COVID-19 compared with before or without COVID-19. This elevation was less marked in people who were vaccinated before COVID-19. In people with COVID-19 before vaccination was available, incidence of mental illnesses remained elevated more than 28 weeks after diagnosis, particularly in people who were hospitalized. In subgroup analyses according to history of the outcome, associations 1 through 4 weeks after COVID-19 were greater in those with than without history. Subgroup analyses also suggested stronger associations in older age groups and in men. The association of COVID-19 with mental illnesses did not differ markedly between ethnic groups.

Attenuation of adverse effects of COVID-19 on mental illnesses in the vaccinated may be explained by reduced disease severity due to vaccination. 22 Potential mechanisms include reduced systemic inflammation and psychological benefits of vaccination, such as reduced concern about COVID-19 and increased social engagement. 23 A previous study 3 found that associations varied by COVID-19 severity, with poorer mental illness outcomes only found among those who were bedridden with COVID-19.

Rates of mental illness outcomes declined with increasing time since COVID-19, although incidence remained elevated up to a year after COVID-19 with hospitalization in the pre–vaccine availability era. Previous findings have been mixed, with a review reporting no clear long-term associations between COVID-19 and mental illness, 24 while a multicohort study found little evidence of attenuation over time. 1 Persisting associations of COVID-19 with mental illnesses could partly reflect ongoing impacts of post–COVID-19 condition. 25 , 26

Consistent with previous research, 1 we found stronger associations between COVID-19 and mental illnesses among older age groups. This is likely to reflect their increased risk of severe COVID-19 and resulting increased anxiety about its outcomes. The association between COVID-19 and mental illnesses was slightly stronger among men, who have been found to be at greater risk of severe mental illness outcomes than women. 27 These patterns contrast with the wider impacts of the pandemic on mental health, which have been found to be greatest in adults aged 25 to 44 years, women, and those with higher educational degrees. 28 This indicates that mechanisms linking COVID-19 and mental health may differ from those underpinning wider pandemic effects.

Our findings highlight the wider public health benefits of vaccination. Prior mental illness may influence vaccine uptake, highlighting the importance of actively encouraging vaccination of people with mental health difficulties. 21 , 29 , 30 Our analyses suggested that the adverse associations of COVID-19 with mental illnesses were greater prior to the availability of vaccination. This may reflect greater uncertainty and public concern around outcomes of COVID-19 and treatment effectiveness at the beginning of the pandemic.

Strengths of this study include the large sample size, the detailed linked electronic health record data, the relatively long duration of follow-up, and the opportunity to account for vaccination. We also note several limitations. First, electronic health records are routinely collected data for health care provision and so only capture conditions diagnosed and recorded by the health care professional rather than true incidence in the population. Unvaccinated people may have been less likely to contact health services and to test for SARS-CoV-2 infection, leading to underestimated effects. People with recorded COVID-19, particularly COVID-19 with hospitalization, may be more likely to have mental illnesses recorded due to greater contact with health services. This may underpin the particularly high HRs observed initially, especially in those hospitalized, and the rapid fall as service contact is likely highest early after diagnosis. However, this is unlikely to fully explain adverse effects, given the persistent elevation of incidence of mental illnesses following COVID-19 with hospitalization and the variation across mental illnesses. Also, people with prior recorded mental health diagnoses may not have them coded at every visit, even if their mental health had deteriorated due to COVID-19. Additionally, data on mental health are generally incomplete, as they do not include mental health services data or National Health Service Talking Therapies (formerly Improving Access to Psychological Therapies), to which patients can self-refer. This is relevant to the present study as those with more serious COVID-19 are more likely to be in contact with health services and therefore may be more likely to report symptoms, while those not in contact may not seek help or may use other routes that are not captured. Again, this relates to the particularly high HRs observed initially, which may reflect the recording of both COVID-19 and mental illnesses during the same consultation. Furthermore, we could only assess COVID-19 severity according to hospitalization and did not consider the potential role of repeated infections. We cannot exclude the possibility of unmeasured confounding, although we controlled for a wide range of demographic characteristics and prior morbidities. More sophisticated methods for potential confounding exist and may have been more appropriate here, although these more computationally intensive methods were not feasible given the size of dataset analyzed. 31 A previous study 2 found that the mental health impacts of COVID-19 were less apparent when using a negative control group (a group of individuals whose SARS-CoV-2 polymerase chain reaction or antigen test result had a negative result), suggesting that observed associations may have been, at least in part, due to unmeasured confounding related to testing behavior. We were not able to include a negative control group to explore this as the available test data did not include negative results. Additionally, other viruses may have implications for mental illnesses. Our findings may therefore reflect a phenomenon that occurs after many viruses rather than specifically SARS-CoV-2.

The findings in this study add to a growing body of evidence highlighting the increased risk of mental illnesses following COVID-19 diagnosis, with stronger associations found in relation to nonvaccination and more severe COVID-19 disease and longer-term associations relating mainly to new-onset mental illnesses. This has important implications for public health and mental health service provision, as serious mental illnesses are associated with more intensive health care needs and longer-term health and other adverse effects. Our results highlight the importance COVID-19 vaccination in the general population and particularly among those with mental illnesses, who may be at higher risk of both SARS-CoV-2 infection and adverse outcomes following COVID-19.

Accepted for Publication: May 21, 2024.

Published Online: August 21, 2024. doi:10.1001/jamapsychiatry.2024.2339

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Walker VM et al. JAMA Psychiatry .

Corresponding Author: Jonathan Sterne, PhD, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, United Kingdom ( [email protected] ).

Author Contributions: Dr Walker had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Walker, Patalay, and Cuitun Coronado contributed equally. Drs Chaturvedi, Macleod, John, and Sterne contributed equally.

Concept and design : V. Walker, Patalay, Cuitun Coronado, Denholm, Forbes, Moltrecht, Palmer, Thompson, Taylor, Cezard, Wood, Chaturvedi, Macleod, John, Sterne.

Acquisition, analysis, or interpretation of data : V. Walker, Patalay, Cuitun Coronado, Stafford, Moltrecht, Palmer, A. Walker, Cezard, Horne, Wei, Al Arab, Knight, Fisher, Massey, Davy, Mehrkar, Bacon, Goldacre, Wood, Chaturvedi, Macleod, John, Sterne.

Drafting of the manuscript : V. Walker, Patalay, Cuitun Coronado, Stafford, John, Sterne.

Critical review of the manuscript for important intellectual content : All authors.

Statistical analysis : V. Walker, Cuitun Coronado, Denholm, Palmer, Taylor, Cezard, Horne, Wei, Knight, Wood, Sterne.

Obtained funding : Patalay, Goldacre, Chaturvedi, Sterne.

Administrative, technical, or material support : V. Walker, Cuitun Coronado, Denholm, Stafford, A. Walker, Thompson, Wei, Al Arab, Massey, Davy, Mehrkar, Bacon, Goldacre, Sterne.

Supervision : V. Walker, Patalay, Cuitun Coronado, Denholm, Palmer, Fisher, Chaturvedi, Macleod, John, Sterne.

Conflict of Interest Disclosures: Dr A. Walker reported grants from the National Institute for Health and Care Research (NIHR) during the conduct of the study. Dr Mehrkar reported grants obtained from the Bennett Foundation, Wellcome Trust, NIHR Oxford Biomedical Research Centre, NIHR Applied Research Collaboration Oxford and Thames Valley, Mohn-Westlake Foundation, and National Health Service (NHS) England during the conduct of the study and consultancy fees from Induction Healthcare and is a senior clinical researcher at the University of Oxford in the Bennett Institute and from the Royal College of General Practitioners (RCGP)/British Medical Association (member of the RCGP health informatics group) and the NHS Digital General Practice Extraction Service (advisory group that advises on access to general practice data for pandemic planning and research outside the submitted work. Dr Chaturvedi reported grants from UK Research and Innovation (UKRI) during the conduct of the study and personal fees from AstraZeneca (data monitoring and safety committee member) outside the submitted work. Dr Sterne reported grants from the UK National Institute for Health and Care Research, UKRI Medical Research Council, and Health Data Research UK during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by the COVID-19 Longitudinal Health and Wellbeing National Core Study, which is funded by the Medical Research Council (MRC) (MC_PC_20059) and the National Institute for Health and Care Research (NIHR) (COV-LT-0009). Dr V. Walker is also supported by the Medical Research Council (MRC) Integrative Epidemiology Unit at the University of Bristol (MC_UU_00032/03). Dr Wei was supported by a UK Research and Innovation (UKRI) MRC (MC/W021358/1) and received funding from UKRI Engineering and Physical Sciences Research Council impact acceleration account (EP/X525789/1). Dr Mehrkar received funding from the Bennett Foundation, Wellcome Trust, NIHR Oxford Biomedical Research Centre, NIHR Applied Research Collaboration Oxford and Thames Valley, and the Mohn-Westlake Foundation. The OpenSAFELY Platform is supported by grants from the Wellcome Trust (222097/Z/20/Z) and the MRC (MR/V015737/1, MC_PC_20059, and MR/W016729/1). In addition, development of OpenSAFELY has been funded by the Longitudinal Health and Wellbeing strand of the National Core Studies programme (MC_PC_20030: MC_PC_20059), the NIHR-funded CONVALESCENCE programme (COV-LT-0009), the NIHR (NIHR135559 and COV-LT2-0073), and the Data and Connectivity National Core Study funded by UK Research and Innovation (MC_PC_20058) and Health Data Research UK (HDRUK2021.000).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: A complete list of the members of the Longitudinal Health and Wellbeing COVID-19 National Core Study appears in Supplement 2 .

Data Sharing Statement: See Supplement 3 .

Additional Contributions: We are very grateful for all the support received from the TPP Technical Operations team throughout this work and for generous assistance from the information governance and database teams at the National Health Service (NHS) England and the NHS England Transformation Directorate. We thank the CONVALESCENCE Study Long COVID PPIE group for their input and for sharing their experiences and expertise throughout the duration of the project.

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In kids, long-COVID symptoms differ by age-group, find scientists who built research index

Drazen Zigic / iStock

Today in JAMA , researchers who developed an index to help identify US youth likely to have long COVID find that symptoms differ and cluster into distinct presentations by age-group.

The Researching COVID to Enhance Recovery (RECOVER)-Pediatrics Group Authors conducted an observational  study involving 5,376 children aged 6 to 17 years who tested positive or negative for COVID-19 at 60 US healthcare and community settings from March 2022 to December 2023. 

The study, funded by the National Institutes of Health (NIH), was based on caregiver-completed symptom surveys and Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Scales.

Child, adult long COVID not the same

The youth were categorized into two age-groups—6 to 11 and 12 to 17 years—and asked about the presence of 89 long-COVID symptoms in nine domains. The median time between first COVID-19 infection and the symptom survey was 506 days for younger children and 556 for adolescents.

In the younger group, 751 of 898 participants (84%) had tested positive for COVID-19, 147 were uninfected, the average participant age was 8.6 years, 49% were girls, 60% were White, 34% were Hispanic, and 11% were Black.

Most research characterizing long COVID symptoms is focused on adults, which can lead to the misperception that long COVID in children is rare or that their symptoms are like those of adults.

David Goff, MD, PhD

The older group was made up of 4,469 adolescents, of whom 3,109 (70%) were infected, and 1,360 were uninfected. The average age was 14.8 years, 48% were girls, 73% were White, 21% were Hispanic, and 13% were Black.

"Most research characterizing long COVID symptoms is focused on adults, which can lead to the misperception that long COVID in children is rare or that their symptoms are like those of adults," David Goff, MD, PhD, director for the Division of Cardiovascular Sciences at the NIH’s National Heart, Lung, and Blood Institute, said in an NIH  news release .

"Because the symptoms can vary from child to child or present in different patterns, without a proper characterization of symptoms across the life span, it's difficult to know how to optimize care for affected children and adolescents," said Goff, who was not a study author.

Symptom clusters tied to poorer health

In total, 45% of infected and 33% of uninfected school-aged children and 39% of infected and 27% of uninfected adolescents reported at least one persistent symptom, also known as post-acute sequelae of SARS-CoV-2 infection (PASC). Twenty-six symptoms in infected younger children and 18 symptoms in infected adolescents lingered in at least 5% of participants.

Symptom clusters most tied to infection formed the basis of the PASC research index for each age-group and correlated with worse overall health and quality of life. In the younger group, pain and neurocognitive and gastrointestinal symptoms dominate the index, while abnormal smell or taste, pain, and fatigue figure more prominently in adolescents.

PASC index thresholds were established at 5.5 in the younger group and 5.0 older participants. A total of 20% of infected and 4% of uninfected school-aged children and 14% of infected and 3% of uninfected adolescents met or exceeded this threshold. This proportion was higher for participants infected before the SARS-CoV-2 Omicron variant emerged than after (21% vs 14% for younger children and 17% vs 7% for older participants).

The most common long-term symptoms among school-aged children with probable PASC that also contributed to the research index were headache (57%); problems with memory, focus, and sleep (44%); and stomach pain (43%). The most common symptoms that weren't included in the index were pain (51%), daytime sleepiness (49%), and anxiety (47%).

'Similar but distinguishable'

The four symptom clusters in younger children were: (1) high rates of many symptoms; (2) headache (95%), pain (60%), and daytime sleepiness (52%); (3) trouble sleeping (64%) and trouble with memory or focus (62%); and (4) stomach pain (100%) and nausea or vomiting (61%). 

Among adolescents, three clusters were identified: (1) high rates of many symptoms, (2) daytime sleepiness (89%) and pain (87%), and (3) impaired smell or taste (100%) and relatively low rates of other symptoms. 

Symptom patterns were similar but distinguishable between school-age children and adolescents, highlighting the importance of characterizing PASC separately in different age groups.

The most common index-contributing persistent symptoms among PASC-probable adolescents were daytime sleepiness (80%), pain (60%), headache (55%), and memory and focus problems (47%). Of symptoms that didn't contribute to the index, the most common were trouble sleeping (47%), anxiety (47%), and depression (38%).

"Symptom patterns were similar but distinguishable between school-age children and adolescents, highlighting the importance of characterizing PASC separately in different age groups," the investigators wrote.

In an NYU Langone Health  news release , lead author Rachel Gross, MD, professor in the system's Departments of Pediatrics and Population Health, said, "Our research index is a first step toward a tool that could someday be used to identify long COVID in children and adolescents—a widely understudied group—but it will likely change and expand as we learn more, and is not intended to be used as a clinical tool today."

4 years on, much remains unknown

In a related  editorial , Suchitra Rao, MBBS, of the University of Colorado School of Medicine, said the study may have been limited by the inability to tell whether quality-of-life scores reflected participants' chronic conditions rather than PASC symptoms for those enrolled later in the study, because there were no baseline measurements to determine preinfection status.

"Four years after the initial reports of long COVID, much remains to be discovered regarding the trajectory and strategies for prevention and management, especially in children," she wrote. 

"The general and scientific communities, in particular those who continue to endure symptoms on a daily basis, eagerly await the subsequent findings from RECOVER-Pediatrics, which will help uncover more about long COVID in children."

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An impaired sense of smell could serve as both a potential marker of virus-induced brain damage and a marker of patients susceptible to brain damage.

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A Plant-Heavy Mediterranean Diet Might Protect You From COVID-19, Says New Research

A new review of six studies involving more than 55,000 people suggests that eating more plant-based foods could help to reduce the chance of covid-19 infection.      .

by Charlotte Pointing

August 21, 2024

A growing body of research suggests that the plant-forward Mediterranean diet is one of the healthiest ways to eat. Multiple studies have associated the diet with a reduced risk of chronic disease, including heart disease and cancer. And now, a brand new review indicates that this plant-heavy way of eating—which emphasizes whole foods , like fruits, vegetables, nuts, seeds, whole grains, legumes, and beans—could even reduce the risk of contracting COVID-19.

The review, conducted at the University of North Sumatra in Indonesia and published in the journal Plos One , examined several different observational studies from around the world, collectively involving 55,489 patients. After zooming in on dietary habits in each of the studies, researchers found enough evidence to suggest that the Mediterranean diet might reduce the risk of contracting COVID-19. Researchers also found that the diet might also reduce the severity of symptoms in those who do get sick from the virus.

RELATED: Can a Low-Fat Diet Really Prevent COVID-19? And What About Eating More Plants? Let’s Look at the Research

What is the best diet to prevent COVID-19? 

Out of six studies conducted across Lebanon, Spain, Italy, the US, and Iran, the researchers noted that four revealed a significant correlation between following the Mediterranean diet and a reduced risk of contracting COVID-19. Additionally, one study found a link between higher adherence to the Mediterranean diet and fewer symptoms of COVID-19.

The new review is not the first to suggest a link between eating more plant-based foods and a lower risk of contracting COVID-19. Earlier this year, one study published in the journal BMJ Nutrition Prevention & Health linked a predominantly plant-based diet with a 39 percent reduction in the odds of COVID-19 infection.

Another study published in the same journal in 2021 examined more than 2,880 healthcare workers from six countries, including the US, UK, Germany, Italy, Spain, and France. It suggested that those who followed a plant-based diet were 73-percent less likely to experience moderate-to-severe COVID-19 symptoms.

Symptoms of COVID-19 include (but are not limited to) fever, chills, fatigue, diarrhea, coughs, and muscle aches. In severe cases, it can lead to pneumonia or even organ failure.

It’s important to note that The Centers for Disease Prevention and Control recommends that everyone aged five or older should get one dose of an updated COVID-19 vaccine every year to protect against serious illness.

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Why certain foods might reduce the chance of you getting sick

No single diet or food is an automatic shield against viruses, but the research suggests that eating more of those rich in vitamins, minerals, and antioxidants, like plant-based whole foods, may make you more resilient. 

Antioxidants are particularly important because they help to protect and regulate the immune response. They are also vital when it comes to reducing chronic inflammation in the body—over time, inflammation weakens the immune system, and this makes it easier for viruses to take hold. Inflammation is a key factor when it comes to the severity of COVID-19, in particular.

“Several subtypes of food were inversely associated with COVID-19 risk,” note the researchers in the new review. “Higher olive oil consumption, lower red meat consumption, lower cereal consumption, moderate amounts of alcohol, and higher intake of fruit and nuts reduced COVID-19 risk, and higher consumption of vegetables, fruits, legumes, nuts, whole grains, and fish lowered odds of severe COVID-19.”

The researchers noted that while promising, more research is needed in this area. One drawback of the new review is that most of the participants in the studies self-reported their dietary habits, and this may have led to potential biases in the data.

However, a plant-forward Mediterranean diet has been consistently shown to be positive for our health. It has also been linked with a lower risk of dying from cancer , as well as a reduced risk of developing diseases like dementia , type 2 diabetes, and heart disease. Earlier this year, The US News & World Report named it as the No. 1 diet for our health for the seventh year in a row. 

“The Mediterranean diet focuses on diet quality rather than a single nutrient or food group,” noted the publication. “Numerous studies have shown that it reduces the risk of chronic health conditions, including heart disease and type 2 diabetes while promoting longevity and improving quality of life.”

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For more plant-based stories like this, read:

• Could This New “Miracle Molecule” Stop You From Getting Sick?
• EPA Issues First Emergency Ban in 40 Years on Common Broccoli Pesticide
• A Plant-Based Diet Can Make You Younger, Says New Research

JUMP TO ... Latest News | Recipes | Guides | Health | Shop

Charlotte is a VegNews editor and writer based in sunny Southsea on England's southern coast.

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Almost 10% of US lung transplants go to COVID-19 patients. Researchers are learning why

by Geri Kelley, Michigan State University

Researchers from Michigan State University and Corewell Health, in collaboration with the Cleveland Clinic, have made a significant breakthrough in understanding post-COVID-19 lung complications.

The study, by Xiaopeng Li of MSU, Reda Girgis of Corewell Health and Kun Li of Cleveland Clinic's Florida Research and Innovation Center, was published in the American Journal of Respiratory Cell and Molecular Biology and highlights the role of a gene called ATP12A in promoting lung damage and excessive mucus production following COVID-19 infection.

COVID-19 infection activates this gene in the lungs, initiating progressive lung scarring that can eventually require a lung transplant. The collaboration investigated the biology behind climbing lung transplant rates among patients with post-COVID pulmonary fibrosis. Almost 10% of all lung transplants in the United States now go to COVID-19 patients, according to data from the United Network for Organ Sharing, or UNOS.

"Understanding how and why some individuals develop severe lifelong complications is critical to developing more effective post-COVID lung damage treatment," said Xiaopeng Li, associate professor in the MSU College of Human Medicine's Department of Pediatrics and Human Development.

Collaborating with Kun Li, Xiaopeng Li investigated ATP12A expression in lung samples from individuals undergoing lung transplantation. Clinical samples provided by Reda Girgis, medical director of Corewell Health's lung transplant program and a professor at MSU, confirmed elevated ATP12A levels in individuals with post-COVID-19 pulmonary fibrosis, akin to fibrosis unrelated to COVID-19.

"At Cleveland Clinic, we confirmed COVID-19 infection directly caused ATP12A levels to increase and contributed to pulmonary fibrosis," noted Kun Li.

This discovery lays the groundwork for potential therapeutic interventions, aiming to benefit all pulmonary fibrosis patients, irrespective of their condition's origin. The next step for the researchers is to unravel how infection elevates ATP12A levels and its contribution to pulmonary fibrosis , paving the way for improved treatments in the future.

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