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Paano ko aalagaan ang aking mental health sa panahon ng covid-19, tips para sa mga kabataan.

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Normal lamang na makaramdam ng takot at pagkabalisa sa panahon ng COVID-19, lalo na’t tumatagal ang krisis na ito. Bukod sa pag-alaga ng ating kalusugan upang makaiwas sa coronavirus, mahalaga rin na alagaan natin ang ating mental health habang nananatili sa loob ng bahay.

Huwag hayaang malugmok sa mga negatibong naiisip at huwag mahihiyang humingi ng tulong kung kailangan mo ito.

  • Napag-iinitan ka ba ng mga magulang mo at palagi kang pinapagalitan? Imbis na mainis lang, kausapin sila ng masinsinan at gawing pagkakataon ang pagkakasama-sama sa bahay para makipag-bonding sa mga magulang . Makipagkwentuhan nang mas makilala at maunawaan ninyo ang isa’t isa.  
  • Miss mo na ba ang barkada? Gamitin ang social media, video call, chat o text para kumustahin at makausap ang mga kaibigan . Makinig sa mga mga kwento, naiisip at nararamdaman ng isa’t isa. Let’s survive this together!  
  • Maghanap ng pagkakaabalahan o mapaglilibangan . Subukan mong matutunan ang isang hobby, skill, o talent. Nakakatulong ito sa pagbawas ng anxiety sa panahong ito. Kahit wala ka sa school, pwede ka pa ring matuto ng mga bagong bagay.

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  • Gumawa ng routine at sikaping sundin ito. Pwede kang tumulong sa gawaing bahay sa umaga, mag-practice ng pagtugtog sa hapon, at magbasa para linangin ang kaisipan sa gabi. Gawin ang mga bagay na nagpapasaya sa iyo. Huwag rin kalilimutang mag-relax at magpahinga.  
  • Gumalaw-galaw at magpapawis. Mag-exercise. Gawin ang mga dance challenge sa TikTok o YouTube. Yayain rin ang mga kasama mo sa bahay na sumali sa video para mas masaya! Nakakatulong ang exercise at paggalaw ng katawan sa pagpapalakas ng resistensya laban sa COVID-19 at iba pang mga sakit.  
  • Kahit may na-miss kang mga milestone sa buhay dahil sa quarantine, tulad ng graduation o birthday celebration, kaya mo pa ring lumikha ng memories. Ipagdiwang ang mga achievements at special occasions sa sariling paraan. Mag-photoshoot, vlog, mini-ceremony, at virtual celebration sa social media kasama ang iyong mga kaibigan at kamag-anak.

An illustration of a boy in a toga posing while his parents take his photo

  • Maging isang smart at responsableng netizen. Dahil virtual na ang karamihan sa ating connections, maging maingat at mapanuri online. Suriin ang mga impormasyon at nakakasalamuha online. Mag-share lamang ng mga makabuluhang bagay.   
  • Tumulong sa mga gawaing bahay hangga’t makakaya , lalo na’t kung nahihirapan ang pamilya mo sa panahong ito dahil sa pagkawala ng trabaho o kakulangan ng pangtustos sa mga pangaraw-araw na pangangailangan. Survive as one family tayo!   
  • Kailangan mo ba ng kausap? Hindi ka nag-iisa. Makipag-chat o text sa mga kaibigan o kamag-anak. Kung nakakaramdam ka ng anxiety, may handang makinig sa iyo! 

An illustration of four children with text showing mental health and psychosocial support hotlines

  • Nalulungkot ka ba sa sitwasyong dala ng COVID-19 at sa mga balita tungkol dito? Maging boses ng kabataan at magbigay-inspirasyon sa iba! Nakararanas tayong lahat ng lungkot at hirap dahil sa krisis na ito. Makakatulong ang pag-unawa sa isa’t isa, at pag-share ng saya at pag-asa.   
  • Appreciate life pa rin! Subukan mong maglista ng tatlong bagay na ipinagpapasalamat mo araw-araw. Di mo kailangan i-explain. I-share mo lang. Tuloy ang buhay. Lalaban tayo!

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The Importance of Well-Being on Resiliency of Filipino Adults During the COVID-19 Enhanced Community Quarantine: A Necessary Condition Analysis

Desiderio s. camitan, iv.

1 College of Arts and Sciences, Manila Tytana Colleges, Pasay, Philippines

Lalaine N. Bajin

2 Psycli-Nik Psychological Assessment and Intervention Services, Zamboanga City, Philippines

Associated Data

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

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.

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

R, Pearson correlation coefficient with resiliency; R p , p value of R; Loneliness and health R = −0.211, where p = 0.001. β , standardized beta; B , unstandardized beta; p , probability value of PERMA elements as predictors of resiliency. R 2 of five original PERMA elements including four additional subscales = 0.368.

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.

Confounders between the relationship of PERMA and Resiliency.

R , Pearson correlation coefficient with resiliency; β , standardized beta; B , unstandardized beta; p , probability value of confounders with p < 0.001.

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.

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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 ).

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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.

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

CE-FDH, ceiling envelopment with free disposal hull; CR-FDH, ceiling regression with free disposal hull. The p value reported was estimated with 10,000 permutations and are treated as significant if <0.05. The threshold for statistical significance is arbitrary but commensurate with the example given by Dul et al. (2020) . Accuracy refers to the percentage of observations under the CR-FDH ceiling line. Skewness p is based on One-Sample Kolmogorov-Smirnov Test. Skewness of resiliency scores is −0.78.

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.

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

Re, resiliency; P, positive emotions, E, engagement; R, positive relationships; M, meaning; A, accomplishment; OW, overall well-being; H, health; N, negative emotions; L, loneliness; NN, not necessary.

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

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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ORIGINAL RESEARCH article

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

Desiderio S. Camitan IV

  • 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.

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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.

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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.

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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 ).

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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.

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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.

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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.

mental health essay tagalog

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mental health essay tagalog

Filipinos face the mental toll of the Covid-19 pandemic — a photo essay

BY ORANGE OMENGAN

Depression, anxiety, and other mental health-related illnesses are on the rise among millennials as they face the pressure to be functional amidst pandemic fatigue. Omengan's photo essay shows three of the many stories of mental health battles, of struggling to stay afloat despite the inaccessibility of proper mental health services, which worsened due to the series of lockdowns in the Philippines.

"I was just starting with my new job, but the pandemic triggered much anxiety causing me to abandon my apartment in Pasig and move back to our family home in Mabalacat, Pampanga." 

This was Mano Dela Cruz's quick response to the initial round of lockdowns that swept the nation in March 2020. 

Anxiety crept up on Mano, who was diagnosed with Bipolar Disorder Type II with Attention Deficit Hyperactivity Disorder and Obsessive-Compulsive Personality Disorder traits. The 30-year-old writer is just one of many Filipinos experiencing the mental health fallout of the pandemic. 

Covid-19 infections in the Philippines have reached 1,149,925 cases as of May 17. The pandemic is unfolding simultaneously with the growing number of Filipinos suffering from mental health issues. At least 3.6 million Filipinos suffer from mental, neurological, and substance use disorders, according to Frances Prescila Cuevas, head of the National Mental Health Program under the Department of Health.

As the situation overwhelmed him, Mano had to let go of his full-time job. “At the start of the year, I thought I had my life all together, but this pandemic caused great mental stress on me, disrupting my routine and cutting my source of income,” he said. 

Mano has also found it difficult to stay on track with his medications. “I don’t have insurance, and I do not save much due to my medical expenses and psychiatric consultations. On a monthly average, my meds cost about P2,800. With my PWD (person with disability) card, I get to avail myself of the 20% discount, but it's still expensive. On top of this, I pay for psychiatric consultations costing P1,500 per session. During the pandemic, the rate increased to P2,500 per session lasting only 30 minutes due to health and safety protocols.”

The pandemic has resulted in substantial job losses as some businesses shut down, while the rest of the workforce adjusted to the new norm of working from home. 

Ryan Baldonado, 30, works as an assistant human resource manager in a business process outsourcing company. The pressure from work, coupled with stress and anxiety amid the community quarantine, took a toll on his mental health. 

Before the pandemic, Ryan said he usually slept for 30 hours straight, often felt under the weather, and at times subjected himself to self-harm. "Although the symptoms of depression have been manifesting in me through the years, due to financial concerns, I haven't been clinically diagnosed. I've been trying my best to be functional since I'm the eldest, and a lot is expected from me," he said.

As extended lockdowns put further strain on his mental health, Ryan mustered the courage to try his company's online employee counseling service. "The free online therapy with a psychologist lasted for six months, and it helped me address those issues interfering with my productivity at work," he said.

He was often told by family or friends: "Ano ka ba? Dapat mas alam mo na ‘yan. Psych graduate ka pa man din!" (As a psych graduate, you should know better!)

Ryan said such comments pressured him to act normally. But having a degree in psychology did not make one mentally bulletproof, and he was reminded of this every time he engaged in self-harming behavior and suicidal thoughts, he said.

"Having a degree in psychology doesn't save you from depression," he said. 

Depression and anxiety are on the rise among millennials as they face the pressure to perform and be functional amid pandemic fatigue. 

Karla Longjas, 27, is a freelance artist who was initially diagnosed with major depression in 2017. She could go a long time without eating, but not without smoking or drinking. At times, she would cut herself as a way to release suppressed emotions. Karla's mental health condition caused her to get hospitalized twice, and she was diagnosed with Borderline Personality Disorder in 2019. 

"One of the essentials I had to secure during the onset of the lockdown was my medication, for fear of running out," Karla shared. 

With her family's support, Karla can afford mental health care. 

She has been spending an average of P10,000 a month on medication and professional fees for a psychologist and a psychiatrist. "The frequency of therapy depends on one's needs, and, at times, it involves two to three sessions a month," she added. 

Amid the restrictions of the pandemic, Karla said her mental health was getting out of hand. “I feel like things are getting even crazier, and I still resort to online therapy with my psychiatrist,” she said.

“I've been under medication for almost four years now with various psychologists and psychiatrists. I'm already tired of constantly searching and learning about my condition. Knowing that this mental health illness doesn't get cured but only gets manageable is wearing me out," she added.    In the face of renewed lockdowns, rising cases of anxiety, depression, and suicide, among others, are only bound to spark increased demand for mental health services.  

MANO DELA CRUZ

mental health essay tagalog

Writer Mano Dela Cruz, 30, is shown sharing stories of his manic episodes, describing the experience as being on ‘top of the world.’ Individuals diagnosed with Bipolar Disorder Type II suffer more often from episodes of depression than hypomania. Depressive periods, ‘the lows,’ translate to feelings of guilt, loss of pleasure, low energy, and thoughts of suicide. 

mental health essay tagalog

Mano says the mess in his room indicates his disposition, whether he's in a manic or depressive state. "I know that I'm not stable when I look at my room and it's too cluttered. There are days when I don't have the energy to clean up and even take a bath,” he says. 

mental health essay tagalog

Mano was diagnosed with Bipolar Disorder Type II in 2016, when he was in his mid-20s. His condition comes with Attention Deficit Hyperactivity Disorder and Obsessive-Compulsive Personality Disorder traits, requiring lifelong treatment with antipsychotics and mood stabilizers such as antidepressants.

mental health essay tagalog

Mano resorts to biking as a form of exercise and to release feel-good endorphins, which helps combat depression, according to his psychiatrist.

mental health essay tagalog

Mano waits for his psychiatric consultation at a hospital in Angeles, Pampanga.

mental health essay tagalog

Mano shares a laugh with his sister inside their home. “It took a while for my family to understand my mental health illness,” he says. It took the same time for him to accept his condition.

RYAN BALDONADO

mental health essay tagalog

Ryan Baldonado, 30, shares his mental health condition in an online interview. Ryan is in quarantine after experiencing symptoms of Covid-19.

KARLA LONGJAS

mental health essay tagalog

Karla Longjas, 27, does a headstand during meditative yoga inside her room, which is filled with bottles of alcohol. Apart from her medications, she practices yoga to have mental clarity, calmness, and stress relief. 

mental health essay tagalog

Karla shares that in some days, she has hallucinations and tries to sketch them. 

mental health essay tagalog

In April 2019, Karla was inflicting harm on herself, leading to her two-week hospitalization as advised by her psychiatrist. In the same year, she was diagnosed with Borderline Personality Disorder.  The stigma around her mental illness made her feel so uncomfortable that she had to use a fake name to hide her identity. 

mental health essay tagalog

Karla buys her prescriptive medications in a drug store. Individuals clinically diagnosed with a psychosocial disability can avail themselves of the 20% discount for persons with disabilities.

mental health essay tagalog

Karla Longjas is photographed at her apartment in Makati. Individuals diagnosed with Borderline Personality Disorder (BPD) exhibit symptoms such as self-harm, unstable relationships, intense anger, and impulsive or self-destructive behavior. BPD is a dissociative disorder that is not commonly diagnosed in the Philippines.

This story is one of the twelve photo essays produced under the Capturing Human Rights fellowship program, a seminar and mentoring project

organized by the Philippine Center for Investigative Journalism and the Photojournalists' Center of the Philippines. 

Check the other photo essays here.

mental health essay tagalog

Larry Monserate Piojo – "Terminal: The constant agony of commuting amid the pandemic"

Orange Omengan – "Filipinos face the mental toll of the Covid-19 pandemic"

Lauren Alimondo – "In loving memory"

Gerimara Manuel – "Pinagtatagpi-tagpi: Mother, daughter struggle between making a living and modular learning"

Pau Villanueva – "Hinubog ng panata: The vanishing spiritual traditions of Aetas of Capas, Tarlac"

Bernice Beltran – "Women's 'invisible work'"

Dada Grifon – "From the cause"

Bernadette Uy – "Enduring the current"

Mark Saludes – "Mission in peril"

EC Toledo – "From sea to shelf: The story before a can is sealed"

Ria Torrente – "HIV positive mother struggles through the Covid-19 pandemic"

Sharlene Festin – "Paradise lost"

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[OPINYON] Kasama tayo sa laban para sa mental health

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This is AI generated summarization, which may have errors. For context, always refer to the full article.

[OPINYON] Kasama tayo sa laban para sa mental health

Hindi lamang ito basta may kinalaman o konektado sa isip o pag-iisip kundi sa bahay-kalinga para sa mga baliw. Walang kapagurang biro ang kapag taga-Mandaluyong ka ay tatanungin ka kung sa “loob o sa labas.” 

Pasaring lamang ito sa lugar na kinatatayuan ng National Center for Mental Health (NCMH). 

O mas kilala bilang Mental.

Nagsimula bilang Insular Psychopathic Hospital, ito ay itinayo sa Kalye Nueve de Pebrero, Baryo Mauway, Mandaluyong, sa probinsiya ng Rizal noong Disyembre 17, 1928. Ito ang pinaglipatan ng mga pasyenteng galing sa “Insane Department” ng San Lazaro Hospital noong 1925 at ng City Sanitarium noong 1935.

Kumbaga, noon pa man, problema na rin ang pagdami ng may mga kapansanan sa pag-iisip. Sa kasalukuyan, ang NCMH ay nagsisilbi sa humigit-kumulang 4,000 pasyenteng naka-admit bawat araw at 56,000 konsultasyon kada taon. Ito ay mula sa NCMH lamang.

Ayon 2010 National Census, sa 1.4 milyong Filipinong may kapansanan, 14 porsiyento – o tinatayang 200,000 tao – ang tinatawag na may “mental disability.”

At paparami pa sila nang paparami.

Paano na sila? Silang kung bansagan ay “Abnoy,” “Agooyong,” “Brenda,” “Buang,” “Koala,” “Kulang-kulang,” “Gunggong,” “Luko-luko,” “Lukresia Kasilag,” “Maysayad,” “May Tililing,” “May Topak,” “Praning,” “Retarded,” “Sinto-sinto,” “Siraulo,” “Taong Grasa,” “Timang,” “Wazak,” o iba pang kabilang sa ikatlong pinakakaraniwang kapansanan sa buong bansa?

Sila ba ay ang may sikosis lamang? Kabilang ba rito ang mga nalulong sa alak o droga? Paano ang mga may matinding lungkot at takot? O ang mga nagsasalita nang mag-isa matapos silang salantain ng kalamidad? O ang mga nag-uulyanin? O ang mga bully at binu-bully? O ang mga nang-aabuso at inaabuso? O ang mga naa-adik sa computer games? O social media?

Kung salat na nga ba sila sa buhay, sapat na ba ang batas?

Mga panukala at batas

Marami ang naging pagtatangkang magkaroon ng mga panukalang-batas ukol sa lusog-isip, pero walang nakakapasa sa Senado at Kamara.

Una sa lahat ng panukalang-batas ay ang   ipinasa si Senador Orlando Mercado na Mental Health Act of 1989. Ito sana ang magdedeklara ng isang pambansang patakaran ukol sa lusog-isip, magtatatag ng Board of Mental Health sa Kagawaran ng Kalusugan, at magsasama sa karamdaman sa isip sa saklaw ng Medicare.

Noong 1998, nabuo ang Executive Order 470 na lumikha sa Philippine Council for Mental Health. Diumano, hindi man lamang ito nakapagpulong.

Nagkaroon tayo ng National Mental Health Policy noong 2001 kung kailan ang dating Kalihim ng Kagawaran ng Kalusugan na si Dr. Manuel Dayrit ay bumuo ng maituturing na isang pambansang patakaran para sa lusog-isip.

Magpahanggang isalang ang An Act Establishing A National Mental Health Policy For The Purpose Of Enhancing The Delivery of Integrated Mental Health Services, Promoting And Protecting Persons Utilizing Psychiatric, Neurologic, And Psychosocial Health Services, Appropriating Funds Therefor, And Other Purposes.”

Noong Mayo 2, 2017, nakapasa sa Senado ang Philippine Mental Health Act of 2017 bilangSenate Bill 1354. Tinututukan nito ang pagsasanib sa pangkalahatang   pangangalaga sa kalusugan, kasama ang serbisyong mental, neurolohikal, at sikososyal. Bagamat ang pangunahing awtor nito ay si Senador Risa Hontiveros, na tagapangulo ng komite sa kalusugan sa Senado, kasama niyang nagsulong ng bill sina Senador Loren Legarda, Juan Edgardo Angara, Paolo Benigno Aquino IV, Vicente Sotto III (na ngayon ay Senate President na), Antonio Trillanes IV, at Joel Villanueva.

Maituturing ding kapanalig sa Kamara ng mga Representante sina Teddy Baguilat, Edward Maceda, Pia Cayetano, Karlo Nograles, Romero Quimbo, Chiqui Roa-Puno, Ron Salo, Yul Servo, Tom Villarin, Linabelle Villarica, at Isagani Zarate.

Ngayon, sana makatulong din ito sa tuloy-tuloy na pagiging positibo ng dati-rating negatibong tingin sa mental.

Nitong 21 Hunyo – noong International Day of Yoga mismo – pinirmahan ni President Rodrigo Duterte ang Republic Act 11036, mas kilala bilang Philippine Mental Health Law of 2018, na naglalayong ipagtanggol, itaguyod, at itaas ang antas ng lusog-isip – para mapabuti pa ang pagkakaloob ng kalinga para sa lusog-isip.

Ano ang lusog-isip? 

Teka, ano nga ba itong paulit-ulit na lusog-isip?

Mas kilala sa Ingles bilang “mental health,” ang lusog-isip ay ang estado ng kaginhawahan ng tàong: (a) mulàt sa kaniyang sariling kakayahan, (b) nakakayang harapin ang pangkaraniwang hamon ng buhay, (c) kapaki-pakinabang, at (d) nakakatulong sa pamayanan.  

Ano’t ano man, nariyan pa rin ang suliranin.

Bagamat kinikilala ang malaking papel ng pamahalaan, dapat nating bigyang-diin ang sama-samang tungkulin. Ito ay ang bayanihan ng lahat ng may kinalaman sa pangkalahatang kalusugan ng sambayanan.

Tinatayang may isang psychiatrist lamang sa bawat 200,000 Filipino. Kaya kailangang-kailangan pa rin ang tulong ng mga relihiyoso pati ng mga sikologo at iba pang kung tawagin ay mental health worker.

Halimbawa, noong dumagsa ang mga sakuna, tulad ng Yolanda at iba pa, ipinaloob ng World Health Organization (WHO) at Kagawaran ng Kalusugan ang lusog-isip sa pangunahing pangangailangang pang-kalusugan bilang bahagi ng rehabilitasyon.

Sa pamamagitan ng Mental Health Gap Action Program (mhGAP) na ito, sinanay ang mga doktor, nars, komadrona, at barangay health workers (BHW) na maisulong ang karapatan ng mga may karamdaman sa isip sa pamamagitan ng pagbibigay ng agarang serbisyong pangkalusugan.

Ipinagpapatuloy ito hanggang ngayon. Dahil dito, dumami ang mga doktor mula sa rural health units ang nagkukusang tumingin sa mga problema sa lusog-isip.

Pinalalakas na rin ang sistema upang maging regular ang rasyon ng gamot para sa kanila. Wala na itong ipinagkaiba sa mga suplay ng lunas para sa altapresyon, diabetes, impeksiyon, at iba pang pangkaraniwang sakit.

Pagkilos para sa mental health

Sa kasalukuyan, kaliwa’t kanan ang mga pulong ng iba’t ibang sektor ng lipunan para tiyakin ang tamang pagpapatupad ng naturang RA 11036.

Kasama rin tayo sa labang ito.

Ano’ng magagawa mo?

Simulan natin sa ating sarili.

Kung araw-araw nagagawa nating magsepilyo o magkaroon ng dental hygiene, bakit hindi natin gawin ang ating mental hygiene?

Ito ang agham ng pananatili ng lusog-isip na naging isang interdisiplaryong larangan na yumayakap sa sikolohiya, narsing, gawaing panlipunan, batas, at iba pang propesyon. Kabilang dito ay ang pagkakaroon ng malusog na asal upang maiwasan ang karamdamang mental.

Una, sanaying maging positibo. Matutong magpasalamat.

Ikalawa, kontrolin ang emosyon. Ipahayag ang damdamin mo sa tamang paraan.

Ikatlo, labanan ang istres. Panatilihin ang pangkalahatang kalusugan.

Malalagom natin ang mga prinsipyo ng pagkilos sa tulong ng tatlong T: (a) tuon; (b) tukoy; (c) tugon. 

Tuunan natin ng pansin ang lusog-isip.

Tukuyuin natin ang mga nangangailangan ng tulong.

Tugunan natin ang mga pangangailangan nila.

Upang di-malimutan, mangyaring tandaan ang tulang ito: 

Lusog-isip ay isipin At pagtuunan ng pansin. Karamdaman ay tukuyin, Tugunan ang suliranin!

– Rappler.com 

Ang TOYM Awardee for Literature na si Vim Nadera  ay nagtapos ng BS at MA Psychology sa University of Santo Tomas at ng PhD Philippine Studies sa University of the Philippines. Bilang performance art therapist, siya ay nakatulong na sa mga maykanser, may AIDS, nagdodroga, “comfort women,”  batang kalye, inabuso, naipit sa mga kalamidad na likas at likha ng tao, at mga nagdadalamhati. 

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Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review

  • Open access
  • Published: 20 August 2020
  • Volume 55 , pages 1397–1413, ( 2020 )

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  • Andrea B. Martinez   ORCID: orcid.org/0000-0002-4437-769X 1 , 2 ,
  • Melissa Co 3 ,
  • Jennifer Lau 2 &
  • June S. L. Brown 2  

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This systematic review aims to synthesise the evidence on behavioural and attitudinal patterns as well as barriers and enablers in Filipino formal help-seeking.

Using PRISMA framework, 15 studies conducted in 7 countries on Filipino help-seeking were appraised through narrative synthesis.

Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress. They prefer seeking help from close family and friends. Barriers cited by Filipinos living in the Philippines include financial constraints and inaccessibility of services, whereas overseas Filipinos were hampered by immigration status, lack of health insurance, language difficulty, experience of discrimination and lack of acculturation to host culture. Both groups were hindered by self and social stigma attached to mental disorder, and by concern for loss of face, sense of shame, and adherence to Asian values of conformity to norms where mental illness is considered unacceptable. Filipinos are also prevented from seeking help by their sense of resilience and self-reliance, but this is explored only in qualitative studies. They utilize special mental health care only as the last resort or when problems become severe. Other prominent facilitators include perception of distress, influence of social support, financial capacity and previous positive experience in formal help.

We confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as primary barrier, while resilience and self-reliance as coping strategies were cited in qualitative studies. Social support and problem severity were cited as prominent facilitators.

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Introduction

Mental illness is the third most common disability in the Philippines. Around 6 million Filipinos are estimated to live with depression and/or anxiety, making the Philippines the country with the third highest rate of mental health problems in the Western Pacific Region [ 1 ]. Suicide rates are pegged at 3.2 per 100,000 population with numbers possibly higher due to underreporting or misclassification of suicide cases as ‘undetermined deaths’ [ 2 ]. Despite these figures, government spending on mental health is at 0.22% of total health expenditures with a lack of health professionals working in the mental health sector [ 1 , 3 ]. Elevated mental health problems also characterise ‘overseas Filipinos’, that is, Filipinos living abroad [ 4 ]. Indeed, 12% of Filipinos living in the US suffer from psychological distress [ 5 ], higher than the US prevalence rate of depression and anxiety [ 1 ]. Long periods of separation from their families and a different cultural background may make them more prone to acculturative stress, depression, anxiety, substance use and trauma especially those who are exposed to abuse, violence and discrimination whilst abroad [ 6 ].

One crucial barrier to achieving well-being and improved mental health among both ‘local’ and overseas Filipinos is their propensity to not seek psychological help [ 7 , 8 ]. Not only are help-seeking rates much lower than rates found in general US populations [ 9 ], they are also low compared to other minority Asian groups [ 10 ]. Yet, few studies have been published on Filipino psychological help-seeking either in the Philippines or among those overseas [ 11 ]. Most available studies have focused on such factors as stigma tolerance, loss of face and acculturation factors [ 12 , 13 ].

To date, no systematic review of studies on Filipino psychological help-seeking, both living in the Philippines and overseas, has been conducted. In 2014, Tuliao conducted a narrative review of the literature on Filipino mental health help-seeking in the US which provided a comprehensive treatise on cultural context of Filipino help-seeking behavior [ 11 ]. However, new studies have been published since which examine help-seeking in other country contexts, such as Norway, Iceland, Israel and Canada [ 6 , 14 , 15 , 16 ]. Alongside recent studies on local Filipinos, these new studies can provide basis for comparison of the local and overseas Filipinos [ 7 , 8 , 12 , 17 ].

This systematic review aims to critically appraise the evidence on behavioural and attitudinal patterns of psychological help-seeking among Filipinos in the Philippines and abroad and examine barriers and enablers of their help-seeking. While the majority of studies undertaken have been among Filipino migrants especially in the US where they needed to handle additional immigration challenges, studying help-seeking attitudes and behaviours of local Filipinos is important as this may inform those living abroad [ 10 , 13 , 18 ]. This review aims to: (1) examine the commonly reported help-seeking attitudes and behaviors among local and overseas Filipinos with mental health problems; and (2) expound on the most commonly reported barriers and facilitators that influence their help-seeking.

The review aims to synthesize available data on formal help-seeking behavior and attitudes of local and overseas Filipinos for their mental health problems, as well as commonly reported barriers and facilitators. Formal psychological help-seeking behavior is defined as seeking services and treatment, such as psychotherapy, counseling, information and advice, from trained and recognized mental health care providers [ 19 ]. Attitudes on psychological help-seeking refer to the evaluative beliefs in seeking help from these professional sources [ 20 ].

Eligibility criteria

Inclusion criteria for the studies were the following: (1) those that address either formal help-seeking behavior OR attitude related to a mental health AND those that discuss barriers OR facilitators of psychological help-seeking; (2) those that involve Filipino participants, or of Filipino descent; in studies that involve multi-cultural or multi-ethnic groups, they must have at least 20% Filipino participants with disaggregated data on Filipino psychological help-seeking; (3) those that employed any type of study designs, whether quantitative, qualitative or mixed-methods; (4) must be full-text peer-reviewed articles published in scholarly journals or book chapters, with no publication date restrictions; (5) written either in English or Filipino; and (6) available in printed or downloadable format. Multiple articles based on the same research are treated as one study/paper.

Exclusion criteria were: (1) studies in which the reported problems that prompted help-seeking are medical (e.g. cancer), career or vocational (e.g., career choice), academic (e.g., school difficulties) or developmental disorders (e.g., autism), unless specified that there is an associated mental health concern (e.g., anxiety, depression, trauma); (2) studies that discuss general health-seeking behaviors; (3) studies that are not from the perspective of mental health service users (e.g., counselor’s perspective); (4) systematic reviews, meta-analyses and other forms of literature review; and (5) unpublished studies including dissertations and theses, clinical reports, theory or methods papers, commentaries or editorials.

Search strategy and study selection

The search for relevant studies was conducted through electronic database searching, hand-searching and web-based searching. Ten bibliographic databases were searched in August to September 2018: PsychInfo, Global Health, MedLine, Embase, EBSCO , ProQuest , PubMed , Science Direct, Scopus and Emerald Insight. The following search terms were used: “help-seeking behavior” OR “utilization of mental health services” OR “access to mental health services” OR “psychological help-seeking” AND “barriers to help-seeking” OR “facilitators of help-seeking” AND “mental health” OR “mental health problem” OR “mental disorder” OR “mental illness” OR “psychological distress” OR “emotional problem” AND “Filipino” OR “Philippines”. Filters were used to select only publications from peer-reviewed journals. Internet searches through Google Scholar and websites of Philippine-based publications were also performed using the search term “Filipino mental health help-seeking” as well as hand-searching of reference lists of relevant studies. A total of 3038 records were obtained. Duplicates were removed and a total of 2659 records were screened for their relevance based on their titles and abstracts.

Preliminary screening of titles and abstracts of articles resulted in 162 potentially relevant studies, their full-text papers were obtained and were reviewed for eligibility by two reviewers (AM and MC). Divergent opinions on the results of eligibility screening were deliberated and any further disagreement was resolved by the third reviewer (JB). A total of 15 relevant studies (from 24 papers) published in English were included in the review and assessed for quality. There were seven studies with multiple publications (two of them have 3 papers) and a core paper was chosen on the basis of having more comprehensive key study data on formal help-seeking. Results of the literature search are reported in Fig.  1 using the PRISMA diagram [ 21 ]. A protocol for this review was registered at PROSPERO Registry of the Centre for Reviews and Dissemination of the University of York ( https://www.crd.york.ac.uk/PROSPERO ; ID: CRD42018102836).

figure 1

PRISMA flow diagram

Data extraction and quality assessment

Data extracted by the main author were crosschecked by a second reviewer (JB). A data extraction table with thematic headings was prepared and pilot tested for two quantitative and two qualitative studies to check data comparability. Extraction was performed using the following descriptive data: (1) study information (e.g. name of authors, publication date, study location, setting, study design, measurement tools used); (2) socio-demographic characteristics of participants (e.g. sample size, age, gender); and (3) overarching themes on psychological help-seeking behavior and attitudes, as well as barriers and facilitators of help-seeking.

Two reviewers (AM and MC) did quality assessment of the studies separately, using the following criteria: (1) relevance to the research question; (2) transparency of the methods; (3) robustness of the evidence presented; and (4) soundness of the data interpretation and analysis. Design-specific quality assessment tools were used in the evaluation of risk of bias of the studies, namely: (1) Critical Appraisal Skills Programme Qualitative Checklist [ 22 ]; and (2) Quality Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project [ 23 ]. The appraisals for mixed-methods studies were done separately for quantitative and qualitative components to ensure trustworthiness [ 24 ] of the quality of each assessment.

For studies reported in multiple publications, quality assessment was done only on the core papers [ 25 ]. All the papers ( n  = 6) assessed for their qualitative study design (including the 4 mixed-methods studies) met the minimum quality assessment criteria of fair ( n  = 1) and good ( n  = 5) and were, thus, included in the review. Only 11 out of the 13 quantitative studies (including the 4 mixed-methods studies) satisfied the minimum ratings for the review, with five getting strong quality rating. The two mixed-methods studies that did not meet the minimum quality rating for quantitative designs were excluded as sources of quantitative data but were used in the qualitative data analysis because they satisfied the minimum quality rating for qualitative designs.

Strategy for data analysis

Due to the substantial heterogeneity of the studies in terms of participant characteristics, study design, measurement tools used and reporting methods of the key findings, narrative synthesis approach was used in data analysis to interpret and integrate the quantitative and qualitative evidence [ 26 , 27 ]. However, one crucial methodological limitation of studies in this review is the lack of agreement on what constitutes formal help-seeking. Some researchers include the utilization of traditional or indigenous healers as formal help-seeking, while others limit the concept to professional health care providers. As such, consistent with Rickwood and Thomas’ definition of formal help-seeking [ 19 ], data extraction and analysis were done only on those that reported utilization of professional health care providers.

Using a textual approach, text data were coded using both predetermined and emerging codes [ 28 ]. They were then tabulated, analyzed, categorized into themes and integrated into a narrative synthesis [ 29 ]. Exemplar quotations and author interpretations were also used to support the narrative synthesis. The following were the themes on barriers and facilitators of formal help-seeking: (1) psychosocial barriers/facilitators, which include social support from family and friends, perceived severity of mental illness, awareness of mental health issues, self-stigmatizing beliefs, treatment fears and other individual concerns; (2) socio-cultural barriers/facilitators, which include the perceived social norms and beliefs on mental health, social stigma, influence of religious beliefs, and language and acculturation factors; and (3) systemic/structural and economic barriers/facilitators, which include financial or employment status, the health care system and its accessibility, availability and affordability, and ethnicity, nativity or immigration status.

Study and participant characteristics

The 15 studies were published between 2002 and 2018. Five studies were conducted in the US, four in the Philippines and one study each was done in Australia, Canada, Iceland, Israel and Norway. One study included participants working in different countries, the majority were in the Middle East. Data extracted from the four studies done in the Philippines were used to report on the help-seeking behaviors and attitudes, and barriers/facilitators to help-seeking of local Filipinos, while the ten studies conducted in different countries were used to report on help-seeking of overseas Filipinos. Nine studies were quantitative and used a cross-sectional design except for one cohort study; the majority of them used research-validated questionnaires. Four studies used mixed methods with surveys and open-ended questionnaires, and another two were purely qualitative studies that used interviews and focus group discussions. Only three studies recruited participants through random sampling and the rest used purposive sampling methods. All quantitative studies used questionnaires in measures of formal help-seeking behaviors, and western-standardized measures to assess participants’ attitudes towards help-seeking. Qualitative studies utilized semi-structured interview guides that were developed to explore the psychological help-seeking of participants.

A total of 5096 Filipinos aged 17–70 years participated in the studies. Additionally, 13 studies reported on the mean age of participants, with the computed overall mean age at 39.52 (SD 11.34). The sample sizes in the quantitative studies ranged from 70 to 2285, while qualitative studies ranged from 10 to 25 participants. Of the participants, 59% ( n  = 3012) were female which is probably explained by five studies focusing on Filipino women. Ten studies were conducted in community settings, five in health or social centre-based settings and 1 in a university (Table 1 ).

Formal help-seeking behaviors

12 studies examined the formal help-seeking behaviors of Filipinos (Table 2 ), eight of them were from community-based studies and four were from centre-based studies. Nine studies reported on formal help-seeking of overseas Filipinos and three reported on local Filipinos.

Community-based vs health/social centres Data from quantitative community studies show that the rates of formal help-seeking behaviors among the Filipino general population ranged from 2.2% [ 30 ] to 17.5% [ 6 ]. This was supported by reports from qualitative studies where participants did not seek help at all. The frequency of reports of formal help-seeking from studies conducted in crisis centres and online counseling tended to be higher. For instance, the rate of engagement in online counseling among overseas Filipinos was 10.68% [ 31 ], those receiving treatment in crisis centers was 39.32% [ 17 ] while 100% of participants who were victims of intimate partner violence were already receiving help from a women’s support agency [ 8 , 32 ].

Local vs overseas Filipinos’ formal help-seeking The rate of formal psychological help-seeking of local Filipinos was at 22.19% [ 12 ] while overseas rates were lower and ranged from 2.2% of Filipino Americans [ 30 ] to 17.5% of Filipinos in Israel [ 6 ]. Both local and overseas Filipinos indicated that professional help is sought only as a last resort because they were more inclined to get help from family and friends or lay network [ 7 , 16 ].

Attitudes towards formal help-seeking

13 studies reported on participants’ attitudes towards seeking formal help. Seven studies identified family and friends as preferred sources of help [ 7 , 14 , 16 ] rather than mental health specialists and other professionals even when they were already receiving help from them [ 17 , 32 ]. When Filipinos seek professional help, it is usually done in combination with other sources of care [ 13 ] or only used when the mental health problem is severe [ 14 , 16 , 33 ]. Other studies reported that in the absence of social networks, individuals prefer to rely on themselves [ 32 , 33 ].

Community-based vs health/social centres Community-based studies reported that Filipinos have negative attitudes marked by low stigma tolerance towards formal help-seeking [ 7 , 14 , 16 ]. However, different findings were reported by studies conducted in crisis centres. Hechanova et al. found a positive attitude towards help-seeking among users of online counseling [ 31 ], whereas Cabbigat and Kangas found that Filipinos in crisis centres still prefer receiving help from religious clergy or family members, with mental health units as the least preferred setting in receiving help [ 17 ]. This is supported by the findings of Shoultz and her colleagues who reported that Filipino women did not believe in disclosing their problems to others [ 32 ].

Local vs overseas Filipinos Filipinos, regardless of location, have negative attitudes towards help-seeking, except later-generation Filipino migrants who have been acculturated in their host countries and tended to have more positive attitudes towards mental health specialists [ 10 , 13 , 15 , 34 ]. However, this was only cited in quantitative studies. Qualitative studies reported the general reluctance of both overseas and local Filipinos to seek help.

Barriers in formal help-seeking

All 15 studies examined a range of barriers in psychological help-seeking (Table 3 ). The most commonly endorsed barriers were: (1) financial constraints due to high cost of service, lack of health insurance, or precarious employment condition; (2) self-stigma, with associated fear of negative judgment, sense of shame, embarrassment and being a disgrace, fear of being labeled as ‘crazy’, self-blame and concern for loss of face; and (3) social stigma that puts the family’s reputation at stake or places one’s cultural group in bad light.

Local vs overseas Filipinos In studies conducted among overseas Filipinos, strong adherence to Asian values of conformity to norms is an impediment to help-seeking but cited only in quantitative studies [ 10 , 13 , 15 , 34 ] while perceived resilience, coping ability or self-reliance was mentioned only in qualitative studies [ 14 , 16 , 33 ]. Other common barriers to help-seeking cited by overseas Filipinos were inaccessibility of mental health services, immigration status, sense of religiosity, language problem, experience of discrimination and lack of awareness of mental health needs [ 10 , 13 , 18 , 34 ]. Self-reliance and fear of being a burden to others as barriers were only found among overseas Filipinos [ 6 , 16 , 32 ]. On the other hand, local Filipinos have consistently cited the influence of social support as a hindrance to help-seeking [ 7 , 17 ].

Stigmatized attitude towards mental health and illness was reported as topmost barriers to help-seeking among overseas and local Filipinos. This included notions of mental illness as a sign of personal weakness or failure of character resulting to loss of face. There is a general consensus in these studies that the reluctance of Filipinos to seek professional help is mainly due to their fear of being labeled or judged negatively, or even their fear of fueling negative perceptions of the Filipino community. Other overseas Filipinos were afraid that having mental illness would affect their jobs and immigration status, especially for those who are in precarious employment conditions [ 6 , 16 ].

Facilitators of formal help-seeking

All 15 studies discussed facilitators of formal help-seeking, but the identified enablers were few (Table 4 ). Among the top and commonly cited factors that promote help-seeking are: (1) perceived severity of the mental health problem or awareness of mental health needs; (2) influence of social support, such as the presence/absence of family and friends, witnessing friends seeking help, having supportive friends and family who encourage help-seeking, or having others taking the initiative to help; and (3) financial capacity.

Local vs overseas Filipinos Studies on overseas Filipinos frequently cited financial capacity, immigration status, language proficiency, lower adherence to Asian values and stigma tolerance as enablers of help-seeking [ 15 , 30 , 32 , 34 ], while studies done on local Filipinos reported that awareness of mental health issues and previous positive experience of seeking help serve as facilitator [ 7 , 12 ].

Community-based vs health/social centres Those who were receiving help from crisis centres mentioned that previous positive experience with mental health professionals encouraged their formal help-seeking [ 8 , 17 , 31 ]. On the other hand, community-based studies cited the positive influence of encouraging family and friends as well as higher awareness of mental health problems as enablers of help-seeking [ 12 , 14 , 16 ].

To the best of our knowledge, this is the first systematic review conducted on psychological help-seeking among Filipinos, including its barriers and facilitators. The heterogeneity of participants (e.g., age, gender, socio-economic status, geographic location or residence, range of mental health problems) was large.

Filipino mental health help-seeking behavior and attitudes The rate of mental health problems appears to be high among Filipinos both local and overseas, but the rate of help-seeking is low. This is consistent with findings of a study among Chinese immigrants in Australia which reported higher psychological distress but with low utilization of mental health services [ 35 ]. The actual help-seeking behavior of both local and overseas Filipinos recorded at 10.72% ( n  = 461) is lower than the 19% of the general population in the US [ 36 ] and 16% in the United Kingdom (UK) [ 37 ], and even far below the global prevalence rate of 30% of people with mental illness receiving treatment [ 38 ]. This finding is also comparable with the low prevalence rate of mental health service use among the Chinese population in Hong Kong [ 39 ] and in Australia [ 35 ], Vietnamese immigrants in Canada [ 30 ], East Asian migrants in North America [ 41 ] and other ethnic minorities [ 42 ] but is in sharp contrast with the increased use of professional help among West African migrants in The Netherlands [ 43 ].

Most of the studies identified informal help through family and friends as the most widely utilized source of support, while professional service providers were only used as a last resort. Filipinos who are already accessing specialist services in crisis centres also used informal help to supplement professional help. This is consistent with reports on the frequent use of informal help in conjunction with formal help-seeking among the adult population in UK [ 44 ]. However, this pattern contrasts with informal help-seeking among African Americans who are less likely to seek help from social networks of family and friends [ 45 ]. Filipinos also tend to use their social networks of friends and family members as ‘go-between’ [ 46 ] for formal help, serving to intercede between mental health specialists and the individual. This was reiterated in a study by Shoultz et al. (2009) in which women who were victims of violence are reluctant to report the abuse to authorities but felt relieved if neighbours and friends would interfere for professional help in their behalf [ 32 ].

Different patterns of help-seeking among local and overseas Filipinos were evident and may be attributed to the differences in the health care system of the Philippines and their host countries. For instance, the greater use of general medical services by overseas Filipinos is due to the gatekeeper role of general practitioners (GP) in their host countries [ 47 ] where patients have to go through their GPs before they get access to mental health specialists. In contrast, local Filipinos have direct access to psychiatrists or psychologists without a GP referral. Additionally, those studies conducted in the Philippines were done in urban centers where participants have greater access to mental health specialists. While Filipinos generally are reluctant to seek help, later-generation overseas Filipinos have more positive attitudes towards psychological help-seeking. Their exposure and acculturation to cultures that are more tolerant of mental health stigma probably influenced their more favorable attitude [ 41 , 48 ].

Prominent barrier themes in help-seeking Findings of studies on frequently endorsed barriers in psychological help-seeking are consistent with commonly reported impediments to health care utilization among Filipino migrants in Australia [ 49 ] and Asian migrants in the US [ 47 , 50 ]. The same barriers in this review, such as preference for self-reliance as alternative coping strategy, poor mental health awareness, perceived stigma, are also identified in mental health help-seeking among adolescents and young adults [ 51 ] and among those suffering from depression [ 52 ].

Social and self-stigmatizing attitudes to mental illness are prominent barriers to help-seeking among Filipinos. Social stigma is evident in their fears of negative perception of the Filipino community, ruining the family reputation, or fear of social exclusion, discrimination and disapproval. Self-stigma manifests in their concern for loss of face, sense of shame or embarrassment, self-blame, sense of being a disgrace or being judged negatively and the notion that mental illness is a sign of personal weakness or failure of character [ 16 ]. The deterrent role of mental health stigma is consistent with the findings of other studies [ 51 , 52 ]. Overseas Filipinos who are not fully acculturated to the more stigma-tolerant culture of their host countries still hold these stigmatizing beliefs. There is also a general apprehension of becoming a burden to others.

Practical barriers to the use of mental health services like accessibility and financial constraints are also consistently rated as important barriers by Filipinos, similar to Chinese Americans [ 53 ]. In the Philippines where mental health services are costly and inaccessible [ 54 ], financial constraints serve as a hindrance to formal help-seeking, as mentioned by a participant in the study of Straiton and his colleagues, “In the Philippines… it takes really long time to decide for us that this condition is serious. We don’t want to use our money right away” [ 14 , p.6]. Local Filipinos are confronted with problems of lack of mental health facilities, services and professionals due to meager government spending on health. Despite the recent ratification of the Philippines’ Mental Health Act of 2018 and the Universal Health Care Act of 2019, the current coverage for mental health services provided by the Philippine Health Insurance Corporation only amounts to US$154 per hospitalization and only for acute episodes of mental disorders [ 55 ]. Specialist services for mental health in the Philippines are restricted in tertiary hospitals located in urban areas, with only one major mental hospital and 84 psychiatric units in general hospitals [ 1 ].

Overseas Filipinos cited the lack of health insurance and immigration status without health care privileges as financial barrier. In countries where people have access to universal health care, being employed is a barrier to psychological help-seeking because individuals prefer to work instead of attending medical check-ups or consultations [ 13 ]. Higher income is also associated with better mental health [ 56 ] and hence, the need for mental health services is low, whereas poor socio-economic status is related to greater risk of developing mental health problems [ 57 , 58 ]. Lack of familiarity with healthcare system in host countries among new Filipino migrants also discourages them from seeking help.

Studies have shown that reliance on, and accessibility of sympathetic, reliable and trusted family and friends are detrimental to formal help-seeking since professional help is sought only in the absence of this social support [ 6 , 8 ]. This is consistent with the predominating cultural values that govern Filipino interpersonal relationships called kapwa (or shared identity) in which trusted family and friends are considered as “hindi-ibang-tao” (one-of-us/insider), while doctors or professionals are seen as “ibang-tao” (outsider) [ 59 ]. Filipinos are apt to disclose and be more open and honest about their mental illness to those whom they considered as “hindi-ibang-tao” (insider) as against those who are “ibang-tao” (outsider), hence their preference for family members and close friends as source of informal help [ 59 ]. For Filipinos, it is difficult to trust a mental health specialist who is not part of the family [ 60 ].

Qualitative studies in this review frequently mentioned resilience and self-reliance among overseas Filipinos as barriers to help-seeking. As an adaptive coping strategy for adversity [ 61 ], overseas Filipinos believe that they were better equipped in overcoming emotional challenges of immigration [ 16 ] without professional assistance [ 14 ]. It supports the findings of studies on overseas Filipino domestic workers who attributed their sense of well-being despite stress to their sense of resilience which prevents them from developing mental health problems [ 62 ] and among Filipino disaster survivors who used their capacity to adapt as protective mechanism from experience of trauma [ 63 ]. However, self-reliant individuals also tend to hold stigmatizing beliefs on mental health and as such resort to handling problems on their own instead of seeking help [ 51 , 64 ].

Prominent facilitator themes in help-seeking In terms of enablers of psychological help-seeking, only a few facilitators were mentioned in the studies, which supported findings in other studies asserting that factors that promote help-seeking are less often emphasized [ 42 , 51 ].

Consistent with other studies [ 44 , 49 ], problem severity is predictive of intention to seek help from mental health providers [ 18 , 30 ] because Filipinos perceive that professional services are only warranted when symptoms have disabling effects [ 5 , 53 ]. As such, those who are experiencing heightened emotional distress were found to be receptive to intervention [ 17 ]. In most cases, symptom severity is determined only when somatic or behavioral symptoms manifest [ 13 ] or occupational dysfunction occurs late in the course of the mental illness [ 65 ]. This is most likely due to the initial denial of the problem [ 66 ] or attempts at maintaining normalcy of the situation as an important coping mechanism [ 67 ]. Furthermore, this poses as a hindrance to any attempts at early intervention because Filipinos are likely to seek professional help only when the problem is severe or has somatic manifestations. It also indicates the lack of preventive measure to avert any deterioration in mental health and well-being.

More positive attitudes towards help-seeking and higher rates of mental health care utilization have been found among later-generation Filipino immigrants or those who have acquired residency status in their host country [ 10 , 15 ]. Immigration status and length of stay in the host country are also associated with language proficiency, higher acculturation and familiarity with the host culture that are more open to discussing mental health issues [ 13 ], which present fewer barriers in help-seeking. This is consistent with facilitators of formal help-seeking among other ethnic minorities, such as acculturation, social integration and positive attitude towards mental health [ 43 ].

Cultural context of Filipinos’ reluctance to seek help Several explanations have been proposed to account for the general reluctance of Filipinos to seek psychological help. In Filipino culture, mental illness is attributed to superstitious or supernatural causes, such as God’s will, witchcraft, and sorcery [ 68 , 69 ], which contradict the biopsychosocial model used by mental health care professionals. Within this cultural context, Filipinos prefer to seek help from traditional folk healers who are using religious rituals in their healing process instead of availing the services of professionals [ 70 , 71 ]. This was reaffirmed by participants in the study of Thompson and her colleagues who said that “psychiatrists are not a way to deal with emotional problems” [ 74 , p.685]. The common misconception on the cause and nature of mental illness, seeing it as temporary due to cold weather [ 14 ] or as a failure in character and as an individual responsibility to overcome [ 16 , 72 ] also discourages Filipinos from seeking help.

Synthesis of the studies included in the review also found conflicting findings on various cultural and psychosocial influences that served both as enablers and deterrents to Filipino help-seeking, namely: (1) level of spirituality; (2) concern on loss of face or sense of shame; and (3) presence of social support.

Level of spirituality Higher spirituality or greater religious beliefs have disparate roles in Filipino psychological help-seeking. Some studies [ 8 , 14 , 16 ] consider it a hindrance to formal help-seeking, whereas others [ 10 , 15 ] asserted that it can facilitate the utilization of mental health services [ 15 , 73 ]. Being predominantly Catholics, Filipinos had drawn strength from their religious faith to endure difficult situations and challenges, accordingly ‘leaving everything to God’ [ 74 ] which explains their preference for clergy as sources of help instead of professional mental health providers. This is connected with the Filipino attribution of mental illness to spiritual or religious causes [ 62 ] mentioned earlier. On the contrary, Hermansdottir and Aegisdottir argued that there is a positive link between spirituality and help-seeking, and cited connectedness with host culture as mediating factor [ 15 ]. Alternately, because higher spirituality and religiosity are predictors of greater sense of well-being [ 75 ], there is, thus, a decreased need for mental health services.

Concern on loss of face or sense of shame The enabler/deterrent role of higher concern on loss of face and sense of shame on psychological help-seeking was also identified. The majority of studies in this review asserted the deterrent role of loss of face and stigma consistent with the findings of other studies [ 51 ], although Clement et al. stated that stigma is the fourth barrier in deterring help-seeking [ 76 ]. Mental illness is highly stigmatized in the Philippines and to avoid the derogatory label of ‘crazy’, Filipinos tend to conceal their mental illness and consequently avoid seeking professional help. This is aligned with the Filipino value of hiya (sense of propriety) which considers any deviation from socially acceptable behavior as a source of shame [ 11 ]. The stigmatized belief is reinforced by the notion that formal help-seeking is not the way to deal with emotional problems, as reflected in the response of a Filipino participant in the study by Straiton et. al., “It has not occurred to me to see a doctor for that kind of feeling” [ 14 , p.6]. However, other studies in this review [ 12 , 13 ] posited contrary views that lower stigma tolerance and higher concern for loss of face could also motivate psychological help-seeking for individuals who want to avoid embarrassing their family. As such, stigma tolerance and loss of face may have a more nuanced influence on help-seeking depending on whether the individual avoids the stigma by not seeking help or prevent the stigma by actively seeking help.

Presence of social support The contradictory role of social networks either as helpful or unhelpful in formal help-seeking was also noted in this review. The presence of friends and family can discourage Filipinos from seeking professional help because their social support serves as protective factor that buffer one’s experience of distress [ 77 , 78 ]. Consequently, individuals are less likely to use professional services [ 42 , 79 ]. On the contrary, other studies have found that the presence of friends and family who have positive attitudes towards formal help-seeking can promote the utilization of mental health services [ 8 , 80 ]. Friends who sought formal help and, thus, serve as role models [ 14 ], and those who take the initiative in seeking help for the distressed individual [ 32 ] also encourage such behavior. Thus, the positive influence of friends and family on mental health and formal help-seeking of Filipinos is not merely to serve only as emotional buffer for stress, but to also favourably influence the decision of the individual to seek formal help.

Research implications of findings

This review highlights particular evidence gaps that need further research: (1) operationalization of help-seeking behavior as a construct separating intention and attitude; (2) studies on actual help-seeking behavior among local and overseas Filipinos with identified mental health problems; (3) longitudinal study on intervention effectiveness and best practices; (4) studies that triangulate findings of qualitative studies with quantitative studies on the role of resilience and self-reliance in help-seeking; and (5) factors that promote help-seeking.

Some studies in this review reported help-seeking intention or attitude as actual behaviors even though they are separate constructs, hence leading to reporting biases and misinterpretations. For instance, the conflicting findings of Tuliao et al. [ 12 ] on the negative association of loss of face with help-seeking attitude and the positive association between loss of face and intention to seek help demonstrate that attitudes and intentions are separate constructs and, thus, need further operationalization. Future research should strive to operationalize concretely these terms through the use of robust measurement tools and systematic reporting of results. There is also a lack of data on the actual help-seeking behaviors among Filipinos with mental illness as most of the reports were from the general population and on their help-seeking attitudes and intentions. Thus, research should focus on those with mental health problems and their actual utilization of healthcare services to gain a better understanding of how specific factors prevent or promote formal help-seeking behaviors.

Moreover, the majority of the studies in this review were descriptive cross-sectional studies, with only one cohort analytic study. Future research should consider a longitudinal study design to ensure a more rigorous and conclusive findings especially on testing the effectiveness of interventions and documenting best practices. Because of the lack of quantitative research that could triangulate the findings of several qualitative studies on the detrimental role of resilience and self-reliance, quantitative studies using pathway analysis may help identify how these barriers affect help-seeking. A preponderance of studies also focused on discussing the roles of barriers in help-seeking, but less is known about the facilitators of help-seeking. For this reason, factors that promote help-seeking should be systematically investigated.

Practice, service delivery and policy implications

Findings of this review also indicate several implications for practice, service delivery, intervention and policy. Cultural nuances that underlie help-seeking behavior of Filipinos, such as the relational orientation of their interactions [ 81 ], should inform the design of culturally appropriate interventions for mental health and well-being and improving access and utilization of health services. Interventions aimed at improving psychological help-seeking should also target friends and family as potential and significant influencers in changing help-seeking attitude and behavior. They may be encouraged to help the individual to seek help from the mental health professional. Other approaches include psychoeducation that promotes mental health literacy and reduces stigma which could be undertaken both as preventive and treatment strategies because of their positive influence on help-seeking. Strategies to reduce self-reliance may also be helpful in encouraging help-seeking.

This review also has implications for structural changes to overcome economic and other practical barriers in Filipino seeking help for mental health problems. Newly enacted laws on mental health and universal healthcare in the Philippines may jumpstart significant policy changes, including increased expenditure for mental health treatment.

Since lack of awareness of available services was also identified as significant barrier, overseas Filipinos could be given competency training in utilizing the health care system of host countries, possibly together with other migrants and ethnic minorities. Philippine consular agencies in foreign countries should not merely only resort to repatriation acts, but could also take an active role in service delivery especially for overseas Filipinos who experience trauma and/or may have immigration-related constraints that hamper their access to specialist care.

Limitations of findings

A crucial limitation of studies in this review is the use of different standardized measures of help-seeking that render incomparable results. These measures were western-based inventories, and only three studies mentioned using cultural validation, such as forward-and-back-translations, to adapt them to cross-cultural research on Filipino participants. This may pose as a limitation on the cultural appropriateness and applicability of foreign-made tests [ 73 ] in capturing the true essence of Filipino experience and perspectives [ 74 ]. Additionally, the majority of the studies used non-probability sampling that limits the generalizability of results. They also failed to measure the type of assistance or actual support sought by Filipinos, such as psychoeducation, referral services, supportive counseling or psychotherapy, and whether or not they are effective in addressing mental health concerns of Filipinos. Another inherent limitation of this review is the lack of access to grey literature, such as thesis and dissertations published in other countries, or those published in the Philippines and are not available online. A number of studies on multi-ethnic studies with Filipino participants do not provide disaggregated data, which limits the scope and inclusion of studies in this review.

This review has confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as a primary barrier resilience and self-reliance as coping strategies were also cited, especially in qualitative studies, but may be important in addressing issues of non-utilization of mental health services. Social support and problem severity were cited as prominent facilitators in help-seeking. However, different structural, cultural and practical barriers and facilitators of psychological help-seeking between overseas and local Filipinos were also found.

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Martinez, A.B., Co, M., Lau, J. et al. Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review. Soc Psychiatry Psychiatr Epidemiol 55 , 1397–1413 (2020). https://doi.org/10.1007/s00127-020-01937-2

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