EMOTIONAL RESPONSES AND SELF-PROTECTIVE BEHAVIORS AMONG

ADULTS WITH COMORBIDITIES DURING COVID-19 PANDEMIC

A Thesis Proposal
Presented to the Faculty
of the College of Health Sciences,
Department of Nursing
University of Southern Philippines Foundation
Cebu City

In Partial Fulfillment of the Requirements for the degree of

Bachelor of Science in Nursing

JADE CATHERINE N. MATUGUINAS

ANGEL L. REVIL
LOUISE FAITH M. RUIZ
JESSA MAE L. TAYO
Researchers

ODILON MAGLASANG, RN, LPT, MAN, EdD

Adviser

January 2022
 Table of Contents

Title Page ................................................................................................................ i

Table of Contents .................................................................................................... ii

List of Figures ........................................................................................................ iii

Chapter 1 The Problem and Its setting

Introduction ..............................................................................................................1

Review of Related Literature and Studies ...............................................................7

Theoretical Background .........................................................................................19

Conceptual Background .........................................................................................21

Statement of the Problem ......................................................................................22

Statement of the Hypotheses..................................................................................23

Significance of the Study .......................................................................................24

Definition of Terms................................................................................................26

Chapter 2 Methodology

Research Design.....................................................................................................27

Research Environment ...........................................................................................27

Research Respondents ...........................................................................................28

Research Instruments .............................................................................................29

Research Procedure ................................................................................................31

Ethical Considerations ...........................................................................................32

Statistical Analysis...……………………………………………………..............36

References ............................................................................................................. 39
Appendix

A Ethics Informed Consent Form ................................................................. 54

B Research Instrument.................................................................................. 57

Curriculum Vitae ............................................................................................................ 61

 List of Figures

Figure No. Title of the Figure Page No.

1 Schematic Diagram of the Study .............................................................. 21

 Chapter 1

The Problem and Its Setting

The World Health Organization declared the coronavirus disease (COVID-19) as a

worldwide pandemic on March 11, 2020. It is an infectious disease caused by the SARS-

CoV-2 virus. The COVID-19 outbreak has become the worst public health crisis in 21st

century history. Globally, as of February 2, 2022, there have been 380,321,615 confirmed

cases of COVID-19, including 5,680,741 deaths (WHO, 2022).

It has been two years since the first case of SARS-CoV-2 infection was reported in

Wuhan, China. Most people infected with the virus experienced mild to severe

respiratory illness. However, older people and those with underlying medical conditions

and comorbidities are more likely to develop serious illness (WHO, 2021). This was

supported by the study conducted by Lavezzo et al. (2020) in Italy, wherein results

showed that about 10% of all symptomatic patients presented dyspnoea, severe interstitial

pneumonia, ARDS and multiorgan dysfunction. The majority of patients with symptoms

and more severe clinical patterns had one or more coexisting medical conditions, such as

hypertension, diabetes and cardiovascular disorders, with elevated case fatalities amongst

elderly and frail patients.

The continuous mutations and formation of new variants of the virus made it more

potent in spreading and infecting people, resulting in an unpredictable series of

lockdowns worldwide (Prati & Mancini, 2021). It had caused severe consequences to all

aspects of society and has affected not just health and economy but also psychological

functioning and mental health (Sadiković & et al., 2020).

 2

According to the American Psychological Association (APA), emotion is defined

as complex reaction pattern, involving experiential, behavioral and physiological

elements. Emotional experiences have three components: a subjective experience, a

physiological response and a behavioral or expressive response. Furthermore, an

emotional response is the reaction of the body to a situation primarily given by an outer

influence such as other individuals, groups, things or entities (Schnoor, 2005).

Disasters are often linked to increase cases of emotional health needs from

distress to specific disorders. In this pandemic, emotional health of the people was a vital

casualty; there is fear of death and anxiety of the future among all the people around the

world (Murthy, 2020). Also, emotions have direct health impacts and indirect behavioral

impacts as fear distorts people's decision readiness, deliberation, information acquisition,

risk perception, and thinking (Huang, 2021).

In United States, as of February 2, 2022, there have been 74,500,060 confirmed

cases of COVID-19 with 880,580 deaths (WHO, 2022). COVID-19 pandemic heavily

affected the emotional health of the Americans. In fact, 72% of Americans felt that their

emotional health was disrupted by the outbreak. American experienced fear,

uncertainties, insecurities, and loss of employment which all contributed towards mental

health problems among people (Barnali & Tathagata, 2020).

According to the Barnali and Tathagata (2020), 57% of the American adults

expressed concerns over being exposed to coronavirus, 53% were worried that they or

someone in their family would be sick, 59% worried that their investments would be

negatively affected, 52% worried that they would lose their jobs, 45% worried that they
 3

would lose income, and 74% were worried that the worst from the outbreak was yet to

come.

In Canada, it was reported that even short-term social distancing practices are

associated with increased psychological distress, including elevated levels of overall

distress, such as panic, emotional disturbances, and depression (Best, Law, Roach, &

Wilbiks, 2021).

In India, the country has the second-largest population in the world that suffered

severely from COVID-19 disease (Ghosh, Nundy & Mallick, 2020). According Gopal,

Sharma, and Subramanyam in 2020, anxiety, stress, and depressive symptoms increased

over time among the Indians during the lockdown. Also, in Israel, about 48% of the

public had negative emotional reactions and 20% perceived they were liable to contract

the virus. Moreover, a positive correlation was found between these feelings and the

degree of perceived threat (Levkovich & Shinan-Altman, 2021).

In the Philippines, as of February 2, 2022, the total number of cases reached

3, 577, 298 million wherein 54,097 died, 3,362,904 survived, and 160,297 are active

cases (DOH PH, 2022). The country remained in one of the longest running, strictest

quarantines in the world. In the study conducted by Tee et. al in 2020, results showed that

16.3% had psychological impact of the outbreak as moderate-to-severe; 16.9% reported

moderate-to-severe depressive symptoms; 28.8% had moderate-to-severe anxiety levels;

and 13.4% had moderate-to-severe stress levels among Filipinos.

Self-protective behaviour is enacted by a person to protect themselves from a

threat to their health or safety (West & Michie, 2021). Self-protective behaviour is a vital

weapon for preventing COVID-19 infections (Lee et al., 2019). During the pandemic,
 4

public health experts recommended the enhanced adherence to self-protective measures

(Lep et al., 2020).

In response to prevention of COVID-19 infection, Americans applied several self-

protective behaviours. According to the CDC (2020), 77.3% stayed home except for

essential activities, and 75.1% were always avoiding crowds, 58.2% maintained physical

distancing, and 60.3% always wore a face mask in public. In addition to that, the research

conducted by Stockman, Wood, and Anderson in 2021 showed that approximately 80%

of women avoided face touching, 87.1% used disinfectants, 82.2% covered mouths when

coughing, 86.5% physically distanced from nonhousehold members, and 59.8%

physically distanced from others if sick.

In comparison with the residents from the Germany, Netherlands, and Italy,

residents from the Netherlands less frequently considered a complete social lockdown

effective (59.2%), compared to respondents in Germany (76.6%) or Italy (87.2%). Also,

Italian residents applied enforced social distancing measures and self-initiated hygienic

behaviours more frequently than German and Dutch residents (Meier, 2020). In addition

to that, the results of the study by Lüdecke & von dem Knesebeck in 2020, in Germany

showed that About 88% of the respondents washed their hands more often and longer,

while about 82% avoided (busy) places or reduced personal meetings and contacts.

Disinfectants were used by 58% of the sample, while about 39% adapted their school or

work situation. Only 10% self-quarantined themselves although having no symptoms, 3%

wore face masks and 2.3% took no measures.

In South Korea, researchers investigated the psychological and behavioral

responses during the early stage of Coronavirus disease 2019 (COVID-19) among the
 5

residents, results showed that 67.8% are always practicing hand hygiene, and 63.2% are

always wearing a facial mask when outside. Approximately 50% reported postponing or

cancelling social events, and 41.5% were avoiding crowded places. The study confirmed

the significance of the psychological responses which associated with behavioral

responses and significantly influenced the public’s level of public health emergency

preparedness regarding the COVID-19 pandemic (Lee & You, 2020).

In Japan, the prevalence of the personal protective measures such as hygiene,

social distancing measures, avoiding touching the eyes, nose and mouth, respiratory

etiquette, and self-isolation ranged from 59.8% to 83.8%. In total, 34.7% implemented all

personal protective measures (Machida et al., 2020).

In China, a high level of protective behaviors was reported as indicated by the

high compliance of respondents with official advice (93.8%), ventilation (94.4%), and

social distancing (93.4%). The least compliant tasks in ration to crowd avoidance and

staying at home were also received over 76% compliance (Bi et al., 2021).

In the Philippines, majority of Filipinos continue to comply with basic safety

protocols against Covid-19. There were 75% who always wore face masks when going

out, 67% washed their hands several times a day, 58% always maintained physical

distance, 53% used face shields when in public transportation or public places and

establishments. However, data also showed that compliance for all cited practices are low

in the Visayas and Mindanao but increased in Metro Manila and other parts of Luzon

(Social Weather Stations, 2021).

Patients with comorbidities have always been vulnerable to stressful life

conditions. Therefore, determining the perceived stress and coping strategies among them
 6

is crucial to minimize the mental and emotional health consequences related to the

outbreak (Girma, Ayalew, & Mesafint, 2021).

This study aims to determine the level of emotional responses and self-

protective behaviors among adults with comorbidities, to compare the emotional

responses and self-protective behaviors according to age group and to test the

significant relationship between the two variables.

 7

Review of Literature and Studies

This section of the study presents and discusses the related literature and studies

of the variables to be studied.

Emotional Responses. In 2020, Kleinberg, van der Vegt, and Mozes conducted a

study to measure the emotions during the COVID-19 pandemic by asking the participants

to indicate their emotions and express these in text. Results showed that the dominant

feelings of participants were anxiety/worry, sadness, and fear. In addition, Lima et al.

(2020) found that it is possible to experience depression, anxiety, panic attacks, stress

disorders, post-traumatic stress disorder, and other psychological conditions. These

emotional barriers of negative emotion arise even in people who are not particularly

susceptible to illness when confronted with a virus that could be unfamiliar to the public

(Montemmuro, 2020).

In light of the rapid spread of COVID-19, the disease poses a severe threat to

human life and health, considering its high contagion factor, lethality, and lack of

medication. COVID-19 pandemic affects the physical aspect and the mental state,

causing individuals to have a variety of emotional issues (Gao et al., 2020). Also, it

cannot be denied that social isolation and quarantine are imperative to prevent the spread

of the virus. However, the effects of these measures on emotional wellbeing and mental

health increase the levels of negative emotions and decrease those of positive ones -

leading to several negative psychological, behavioral, and health problems, such as

anxiety and depression (Rossi et al., 2020), abuse of alcohol and drugs, trouble in

concentrating, increased aggressive behavior, maladaptive eating, and worse job

performance (Kirzinger et al., 2020; Smith, 2020).

 8

According to Levkovich and Shinan-Altman (2021), about 48% of the public had

negative emotional reactions, and a positive correlation was found between these feelings

and the degree of perceived threat. Also, the results of their study revealed that the

sources of participants' emotional responses and sense of danger were health concerns

regarding themselves and their loved ones.

In addition, a study conducted in the Philippines showed that Filipinos reported

significantly higher levels of depression, anxiety, and stress than Chinese during the

COVID-19 pandemic. Thus, the researchers suggest that health education and literacy

campaign should be required in the country to alleviate the mental and emotional health

effects (Tee et. al, 2020).

With regards to the emotional responses among adults with chronic diseases,

Girma, Ayalew, and Mesafint in 2021 concluded that a significant number of adult

participants with chronic diseases suffered from moderate to severe perceived stress due

to the COVID-19 outbreak. More than two-thirds of study participants (68.4%) were

moderately stressed, 13.9% were severely stressed, and 17.8% had low perceived stress.

According to Harmon-Jones, Bastian, and Harmon-Jones (2016), these are the

negative discrete emotions of a person. They are presented and discussed in the

succeeding paragraphs.

Anxiety. It is often regarded as a negative, high arousal emotion that is

most likely associated with behavioral conflict. One key neural difference

between fear and anxiety is that the peptide corticotropin-releasing factor (CRF)

has a unique role in anxiety. Also, it is associated with nervousness, worries, and

tenseness (Harmon-Jones, Bastian, & Harmon-Jones, 2016).

 9

A study in Slovenia shown that people’s anxiety tends to increase sharply

at the beginning of a pandemic. The participants reported that they were more

worried and anxious, thought more about the disease, perceived it as more severe

and assessed the chances of containing the disease as worse than before the first

confirmed case of COVID-19 (Sreevidya et al., 2021).

Furthermore, according to Wang et al. (2020), pandemics can be viewed

as events that may cause anxiety in humans, making anxiety one of the

psychological problems that can occur. As a result of stressful life events, anxiety

and is considered prevalent, debilitating, and costly. Also, Ypsilanti (2021)

concluded that a higher level of trait anxiety is associated with higher levels of

loneliness, prosocial behavior, and a greater desire to help others. In contrast,

participants who were low in COVID-related anxiety were more likely to have

assisted someone in need during the pandemic than those with high trait anxiety

levels. Mental health experts publicly expressed concerns that anxiety over

COVID-19 spread faster than COVID-19 (Huang, 2021)

Fear. It is often regarded as a negative, high arousal emotion that is

associated with withdrawal motivational tendencies. Neurally, fear involves

corticotrophin releasing factor, adreno-cortico- trophic-hormone, cholecystokinin,

central and lateral amygdala, anterior and medial hypothalamus, PAG, and the

lower brain stem. Its cluster includes horror, alarm, and terror (Harmon-Jones,

Bastian, & Harmon-Jones, 2016).

According to Huang (2020), in just a month after the outbreak, Americans'

fears over COVID-19 exploded and anxiety about COVID-19 is partly due to
 10

people's fear of the uncertain. Also, a study by Brooks et al. (2020) showed that

the COVID-19 related images and words have taken on a negative implication

mainly associated with fears of viral exposure and death. Exposure to such stimuli

can negatively affect the mental health, as they serve as signals of threat and fear.

In addition to that, Morganstein (2020) suggested that in managing fear

and uncertainty during an outbreak, time and precise information play a vital role

in controlling such mental and emotional health problems. Knowing what to do

helps people feel safer and strengthen their beliefs that they can take action to

protect themselves.

Sadness. It is often conceptualized as a negative, low arousal emotion; it

appears to be mostly associated with the approach motivational system. Neurally,

it involves endorphins, corticotrophin releasing factor, cortisol, glutamate,

midbrain PAG, medial diencephalon, ventral septal area, preoptic area, bed

nucleus of stria terminalis, cingulate gyrus, amygdala, and hypothalamus. Also, it

is mostly associated with suffering, depression, and disappointment (Harmon-

Jones, Bastian, & Harmon-Jones, 2016).

During the pandemic, reduced mobility, social isolation, mandatory

quarantine, and lack of physical touch with family, friends, and meaningful others

can all help to minimize COVID-19 spread in the community, but they also lead

to feelings of loneliness and sadness (Killgore, Cloonan, Taylor & Dailey, 2020).

During the first wave of the COVID-19 pandemic in countries, sadness was

linked to greater levels of depression and anxiety symptoms. Importantly, young

 11

adult individuals are more likely to experience loneliness and associated mental

health difficulties (Bu, Steptoe & Fancourt, 2020).

Anger. It is often regarded as a negative, high arousal emotion that is

associated with approach motivational tendencies. Neurally, it involves

testosterone, substance P (a neuropeptide that acts as a neurotransmitter and

neuromodulator), the medial hypothalamus, amygdala, and the periaqueductal

gray. Its cluster includes rage, irritation, and exasperation terror (Harmon-Jones,

Bastian, & Harmon-Jones, 2016).

Anger and irritability are common emotions in response to stress. Loss of

control and predictability or worries about meeting basic needs can all contribute

to feelings of anger. Sometimes feelings of sadness and anxiety come out as anger

(CDC, 2021).

During the pandemic, confidence in the ability of the government to

handle the COVID-19 outbreak decreased and conflicts about the levels of

COVID-19 risk and non-adherence to protective behaviors caused tension. The

poor knowledge and approval of conspiracy theory and poor understanding of

government measure may be associated with anger and confrontation (Smith,

et.al., 2020). Also, arguments, anger, or falling out with someone as a result of the

COVID-19 pandemic were linked to younger age, as was the belief that they were

more likely to face considerable financial hardship as a result of COVID-19

(Smith, 2021).

Emotional Responses and Age. The discrete emotion theory of affective aging

suggests that anger, but not sadness, becomes increasingly maladjusted during older
 12

adulthood in predicting health-relevant physiological processes and chronic disease

(Kunzmann & Wrosch, 2018).

According to Carstensen, Shavit, and Barnes (2020), age was associated with

relatively greater emotional wellbeing. The findings of their study suggested that older

adults demonstrated somewhat better emotional wellbeing persists even in the face of

prolonged stress. Other researchers supported this idea, wherein they implicated that

there is substantial evidence that, on balance, older people's daily emotional experience is

more favorable than younger people's (Burr, Castrellon, Zald, & Samanez-Larkin, 2020).

Also, older people reported that they manage their emotions better than when they were

younger and displayed more excellent emotional stability in day-to-day life (Burr et al.,

2020).

Furthermore, de Bruin (2021) found that older adult age was associated with less

depression and less anxiety for better overall mental health. His findings agreed with the

study, suggesting that relatively older adults tend to report fewer negative emotions,

better mental health, and less responsiveness to daily stressors (Neubauer et al., 2019).

Also, while the COVID-19 epidemic was outside their control, relatively older adults

may have regulated their emotions by focusing on the positive or choosing activities and

interactions that reduced their stress (Neubauer et al., 2019).

Self-Protective Behaviors. With the onset and spread of COVID-19 worldwide,

the adoption of self-protective behaviors became the norm (Dean et al., 2021; World

Health Organization, 2020). Individuals need to practice self-protection to prevent getting

infected with the virus (Lee et al., 2019).

 13

Following the episode of COVID-19, experts urged adherence to self-protective

measures to be enhanced (Lep et al., 2020). It was hoped that increased personal hygiene

and social distancing would reduce the rapid transmission of COVID-19 (Zickfeld et al.,

2020). The countries with the highest number of cases implied how important it is for

people to know and apply the basic protective measures to reduce the number of cases

(Lep et al., 2020). Thereby, information such as wearing of mask, handwashing, and

social distancing to protect oneself and others have become omnipresent in the media. It

is evident that self-defensive practices are valuable and effective (Eikenberry et al., 2020;

Howard et al., 2021) and should be upheld accordingly.

According to Somrongthong (2016), chronic conditions and lifestyle behaviors

have a harmful influence on the quality of life for adults because of physical disability

and emotional concerns. In addition to that, Farley (2020) claimed that promoting self-

protective behavior can improve patients' outcomes and quality of life with pre-existing

chronic diseases. Also, the research found that people who have consulted with their

doctor are more likely to embrace self-protective behavior, supporting the idea that

doctors have a unique role in delivering information regarding self-protective behavior

(Lin et al., 2018).

During the onset of the COVID-19 outbreak, Huang et al. (2020) conducted a

study to develop a tool that evaluates people's protective behaviors towards COVID-19.

The three dimensions are presented and discussed in the succeeding paragraphs.

Routine Protective Behaviors (RPB). This refers to the individuals'

protective behaviors in daily life during the pandemic. This includes but is not
 14

limited to frequent handwashing, practicing physical distancing, wearing

facemasks and face shields, and the like (Huang et al. 2020).

According to Morganstein (2020), during the COVID-19 pandemic,

people showed awareness of protective behaviors against such disease and

developed health-protective attitudes. All precautionary preventive measures such

as social distancing, proper handwashing or sanitizing with antiseptic gels, using a

tissue or elbow when sneezing or coughing, sanitizing surfaces, and staying home

when curfews were announced and home isolation, when necessary, were

practiced mainly by the people to prevent the spread and avoid getting infected

from the virus (Abolfotouh et al., 2021).

Additionally, Abolfotouh et al. (2021) reported that the majority of

participants in their study reported that they always/often carry their hand

sanitizer when going outdoors (71.5%), comply with proper handwashing

(95.4%), avoid touching their face, nose, or eyes (88.5%), cover nose and mouth

with a tissue when coughing or sneezing (92%), disinfect things like food and

drinks they bring from outside (84.4%), disinfect high touch surfaces (78.4%) and

wear a mask when outdoors (68.3%).

Post-exposure Protective Behaviors (PPB). This refers to the people's

protective behaviors after exposure to possible infection. Protective -Behaviors

included are self-isolation, reporting of family members who just come back from

other countries or areas with high COVID-19 cases for isolation, and many more

(Huang et al. 2020).

 15

According to Wang et al. (2020), COVID-19 outbreaks have been

prevented and controlled through measures such as social isolation, quarantine,

travel restrictions, contact avoidance, and early detection of infected individuals

through various tests. Also, the Center for Disease and Control recommended that

unvaccinated individuals who have been in contact with someone who has

COVID-19 should be quarantined for at least 14 days. For fully vaccinated

individuals, they do not need to be quarantined unless they show some signs and

symptoms of COVID-19; however, they need to get tested after 5-7 days of

exposure. In addition, all individuals who have COVID-19 should be isolated

until they are free of the virus and safe to be with other people.

Post-exposure Risky Behaviors (PRB). This refers to people's risky

behaviors after the possible infective exposure. This includes self-isolation after

symptoms are felt, consulting doctors/getting help from healthcare professionals,

notifying health authorities for confirmed cases at home, and many more (Huang

et al. 2020).

According to Patel et al. (2020), isolation of ill or infected persons from

others is a very effective in dealing with COVID-19 as it spreads from droplets in

the air. This was supported by Pascarella et al. (2020), wherein they claimed that

it is fundamental to ensure patient isolation to avoid transmission to other

patients, family members, and healthcare providers and that infected individuals,

both symptomatic and asymptomatic, and anyone who may have been in contact

with them must be isolated. Also, they suggested that it is best to do self-isolation

if symptoms are only mild to reserve hospital beds for severe cases.
 16

Self-Protective Behaviors and Age. Behavioral changes may differ by age, but

they can also change over time. People may adopt the suggested behavioral modifications

as they become more aware of the risks (Ibuka et al., 2019). This was supported by Liu et

al. (2019), wherein they suggested that self-protective behaviors are not equally adopted

among different groups or settings. In Portugal, researchers found that protective

behaviors decline with increasing age (Pasion et al., 2020). In a recent study of older men

in the U.S., older men implemented fewer behavioral changes than their younger

counterparts (Barber & Kim, 2021).

COVID-19 complications and death risks increase dramatically with age

(Spiegelhalter & Crimmins, 2020). There are several challenges during outbreaks with

aging populations, particularly for older people who are at a higher risk of medical

complications and mortality. Although individuals of all ages can contract COVID-19,

those over the age of 65 have a greater risk of experiencing severe illness because of

cumulative health conditions that are likely to accompany Aging (European Centre for

Disease Prevention and Control, 2020).

Furthermore, according to COVID-19 death reports posted last August 29, 2020,

79 percent of deaths were reported among people 65 and up, and the population fatality

rate (the risk of death from COVID-19 within the population) increased dramatically with

age. Thus, the rate was 0.82% for older people, 0.29% for ages 75-84, 0.12% for ages 65-

74, 0.05% for ages 55-64, and 0.02% for ages 45-54, compared with 0.003% for younger

people (Provisional Death Counts for Coronavirus Disease, 2019).

Emotional Responses and Self-Protective Behaviors. As Simon et al. (2018)

have pointed out, emotions influence or sometimes completely determine the outcome of
 17

a large number of decisions people are confronted with in a day. Therefore, it behooves

all of people who want to make the best, most objective decisions to know all people can

about emotions and their effect on decision-making.

In the first month of the social distance period caused by the COVID-19

pandemic, community-dwelling persons reported emotional issues. Social media channels

remain inundated with nonscientific and conspiratorial assertions, further complicating

the emotional response to the current COVID-19 outbreak (Garrett, 2020). Conspiracy

theories stating that COVID-19 does not have a natural origin, as well as other

supernatural conspiracy beliefs, have evolved among them (Calisher, Carroll, Colwell,

Corley, & Gorbalenya, 2020). Unfortunately, misinformation can lead to fear and

prejudice, which can impede a person's willingness to follow the proper procedures to

avoid the COVID-19, putting his or her own and others' lives in jeopardy (Calisher et al.,

2020).

Furthermore, a study in the Philippines showed that understanding COVID-19

had significant direct effects on perceived vulnerability and perceived severity and

perceived vulnerability and perceived severity had significant indirect effects on intention

to follow COVID-19 protocols and engagement on self-protective behaviors (Prasetyo,

Castillo, Salonga, Sia, & Seneta, 2020)

Individual and communal health, as well as emotional and social functioning, are

all threatened by the COVID-19 pandemic. Threat perception is a key factor in

motivating people toward preventive behaviors. A sense of threat has a positive influence

on people's intentions to take precautions (Kim & Song, 2017). Human cognitive

processes, such as perception, attention, learning, memory, and reasoning, are heavily
 18

influenced by emotion. In addition to modulating selectivity of attention, emotions also

motivate action and behavior. Emotional reactions, according to this viewpoint, emerge

before risk perceptions and behavioral responses and can direct them (Tyng et al., 2017).
 19

Theoretical Background

This study is anchored on the Schacter–Singer theory of Stanley Schachter and

Jerome Singer (1962). Schacter–Singer theory of emotions are the result of both

physiological and cognitive processes (as cited by Mammud et al., 2020). It is also a

cognitive process in which people attempt to understand their physiological responses by

examining their surroundings to determine what is causing them to feel this way

(Gallagher et al., 2020). Physical processes in the body such as the activation of the

sympathetic nervous system, heart starting to beat quicker, sweating, or trembling are

what they called as “physical arousal”. Schacter–Singer theory is thought that

physiological arousal is quite similar throughout the various types of emotions we

experience, and that the cognitive assessment of the event is crucial to the actual feeling

felt. In fact, if the circumstances were ideal, it might be feasible to misattribute arousal to

an emotional experience (Kamalou et al., 2019).

Schacter–Singer theory of emotions for Adults with Comorbidities describes

feeling of being threatened and of anxiety. It is reasonable to assume that those who have

higher and more debilitating levels of social anxiety are more likely to avoid situations

that offer more opportunities for social interaction that could reduce loneliness (Ho et al.,

2020). Greater exposure to stressors related to pandemic could also have contributed to

greater loneliness, forcing people to self-quarantine, making them feel more isolated.

(Lim et al., 2016)

According to this theory, emotions are composed of two factors: physiological

and cognitive (Palmer, 2020). In other words, physiological arousal is interpreted in

context to produce the emotional experience. Those who found COVID-19 to be an

 20

emotional threat showed the highest increase in stress levels and the severity of

depressive symptoms. This increase in psychological distress was seen in all age groups,

but older age groups showed the lowest psychological distress before and during the

blockade (Tee et al., 2020).

Another theory that is related to this study is the Protective Motivation Theory of

Rogers (1975). Protective Motivation Theory states that people formulate their

protection strategies based on their perceptions of four factors: the severity of a

threatening situation, the probability of it occurring, the effectiveness of the

recommended responses, and the ability to adapt to the recommended solutions (as cited

by Al-Rasheedis, 2020). According to Rimer, Glanz, and Rasband (2001), a person's

intention to engage in a behavior is the most important factor influencing the behaviour.

Researchers have often relied on Protection Motivation Theory (PMT) as a framework to

investigate, understand, and predict people's intentions to engage in protective behaviours

(Milne, Sheeran, & Orbell, 2000; Xiao et al., 2016).

By using the PMT to predict protective behaviors, it follows that those who are

most likely to engage in COVID-19 protective behaviors would be those who believe

their own vulnerability to the disease is high, believe that the virus is serious, that

engaging in recommended behaviors will significantly reduce their risk of contracting the

virus, and believe that they can follow through with practices for reducing risk. On the

other hand, those who believe their risk is low, that the disease is mild, and that the

protective measures are ineffective or will not be able to engage in them will report the

lowest frequency of engaging in protective behaviours (Rasheedis, 2020).

 21

Conceptual Background
INPUT PROCESS OUTPUT

1. Demographic profile of
the respondents in terms of:
1.1 age;
1.2 sex at birth;
1.3 highest
educational
attainment; Collection of
1.4 occupation; information
1.5 average monthly
income; and
Submission of
1.6 comorbidities.
Transmittal letters
2. The level of emotional
(Dean and Brgy.
responses of adults with
Captain)
comorbidities.
3. The level of self-
protective behaviors of Proposed Health
Conduction of Intervention Program
adults with comorbidities. Preliminary and
4. Significant difference Main Survey
between the emotional
responses when grouped
according to age. Distribution of
5. Significant difference Survey
between the self-protective Questionnaire
behaviors when grouped
according to age.
6. Significant relationship Collection of Data
between emotional responses
and self-protective behaviors
among adults with Interpretation,
comorbidities. Analysis and
7. Intervention plan that can Implication of Data
be proposed based on the
findings of the study.

Figure 1. Schematic Diagram of the Study

 22

Statement of the Problem

This study aims to determine the level of emotional responses and self-protective

behaviors among adults with comorbidities in Brgy. Luz, Cebu City during COVID-19

Pandemic. This also aims to compare the respondents’ emotional responses and self-

protective behaviors according to age group and to determine the significant relationship

between the two variables. The findings will serve as bases for a proposed health

intervention programs for adults with comorbidities.

Specifically, this study will answer the following questions:

1. What is the demographic profile of the respondents in terms of:

1.1 age;

1.2 sex at birth;

1.3 highest educational attainment;

1.4 occupation;

1.5 average monthly income;

1.6 comorbidities?

2. What is the level of emotional responses of adults with comorbidities?

3. What is the level of self-protective behaviors of adults with comorbidities?

4. Is there a significant difference between the emotional responses when grouped

according to age?

5. Is there a significant difference between the self-protective behaviors when grouped

according to age?

8. Is there a significant relationship between emotional responses and self-protective

behaviors among adults with comorbidities?

9. What intervention plan can be proposed based on the findings of the study?
 23

Statement of the Hypotheses

H01: There is no significant difference in the emotional responses of adults with

comorbidities when grouped according to age.

H02: There is no significant difference in the self-protective behaviors of adults with

comorbidities when grouped according to age.

H03: There is no significant relationship between the emotional responses and self-

protective behaviors among adults with comorbidities.

 24

Significance of the Study

Emotional responses and self-protective behaviors are important in handling

individuals who are at higher risk of severe COVID-19 infection. Focusing on these two

variables, the results of this study would be of great benefit to the following:

Adults with comorbidities. This study will help adults to express their feelings

during the pandemic and how they protect themselves against the virus. Also, This will

help them expand their understanding of the effects of the ongoing pandemic to their

emotional health; and they would also be the beneficiary of the health intervention or

program to be implemented based on their responses.

Significant Others. This study will help significant others get a better

understanding of the ongoing pandemic and its effects on the daily life of their family or

loved ones who are at higher risk of severe COVID-19.

Healthcare Providers. This study may serve as an aid for providers of health

care to have a broader perspective on the condition of their patients at higher risk of

severe COVID-19 infection. Also, this would be guide them in implementing mental and

emotional health programs and services.

Nurses. This may serve as a guide and reference for the nurses in formulating

their care plan for adults with comorbidities during pandemic.

The Researchers. It will augment their knowledge in the aspect of the emotional

responses and its relationship with self-protective behaviors among adults with

comorbidities.
 25

Future Researchers. This research will be a useful reference for researchers who

are planning to make any related study, the standard on which the Bachelor of Science in

Nursing program is based.

 26

Definition of Terms

The researchers offer the following operational definition of terms to provide

enlightenment and similar understanding of the variables used in this study.

Emotional responses. Refer to the emotional reactions that have been felt during

the COVID-19 pandemic such as anxiety, fear, sadness and anger.

Self-protective behaviors. Refer to the self-defensive practices that are being

applied during COVID-19 pandemic such as wearing of mask, handwashing and social

distancing, and etc.

Adults. Refer to individuals who are 20 years old and above which are at risk of

COVID-19 exposure.

Comorbidities. Refer to the presence of two or more medical conditions of the

adult.

Coronavirus disease (COVID-19). Refers to an infectious disease caused by the

SARS-CoV-2 virus which causes mild to severe respiratory illnesses.

COVID-19 pandemic. Refers to the ongoing global pandemic of Coronavirus

disease 2019 (COVID-19) caused by severe acute respiratory Coronavirus 2 (SARS-

COV-2).
 Chapter 2

Methodology

This part of the study confers the research design that the researchers will utilize,

research environment, the research respondents, the research instruments and its

statistical data.

Research Design

This study will use the descriptive-correlational and descriptive-comparative

designs. This study will be descriptive because it will attempt to describe the profile,

emotional responses and self-protective behaviors of adults with comorbidities in Brgy.

Luz, Cebu City. This study will use the comparative research design as it will compare

the significant difference between emotional responses and self-protective behaviors

among adults with comorbidities according to age group. Furthermore, it will be

correlational because it will test the significant relationship between the two variables.

Research Environment

This study will be conducted in Barangay Luz, a barangay located in the City of

Cebu City with an area of 0.5602 km². The barangay boundaries are Kasambagan from

north, Hipodromo from south, Lahug from east and Mabolo from east.

Barangay Luz was the first barangay that was put on lockdown during the

pandemic specifically the Sitio Zapatera. It is also among the barangays in Cebu City

with the highest number of COVID-19 cases.

 28

Research Respondents

The research respondents will be the adults with comorbidities who had no

previous COVID-19 infection in Brgy. Luz, Cebu City. The respondents will be selected

utilizing the purposive sampling. They will be asked to sign an informed consent form in

order for them to be able to participate in this study. Also, to ensure that the number of

respondents is large enough to be meaningful practically and statistically, it is

recommended that the minimum number of respondents be 30 (Lindner, Murphy, &

Briers, 2001).

Inclusion Criteria

Respondents must meet the following criteria to be part of the study:

• Male or Female who has ≥ 20 years of age

• Adults with comorbidities (presence of two or more health conditions)

• No history of COVID-19 infection

• Provide valid informed consent prior to conducting the study

Exclusion Criteria

Respondents will be excluded from the study if any of the following criteria are

present:

• Male or Female who has < 20 years of age

• Adults having only one health condition

• History of COVID-19 infection

• Refusal to give an informed consent

 29

Research Instruments

This study will utilize a three-part instrument. The first part is a demographic

questionnaire which consists of six items designed to collect data about the characteristic

of the respondents. The respondents will be asked to provide details about their age, sex

at birth, highest educational attainment, occupation, average monthly income, and

comorbidities.

The second part will utilize a researcher made instrument adopted from a

validated instrument in US entitled, Pandemic Emotional Impact Scale which is a 16-item

scale from Google Scholar. It is authored by Ballou, Gray, & Palsson in 2020. Each item

is scored on a Likert scale of 5 points ranging from "not at all " (1) to "extremely" (5),

with a total score of 16-80. The PEIS demonstrated excellent internal consistency

(Cronbach’s α = 0.94) and Guttman split-half reliability (0.95). Exploratory factor

analysis suggested two sub-scales – emotional impact and pragmatic worries – but these

were highly correlated with the overall scale score suggesting that the total score can be

used in most cases. The PEIS demonstrated good concurrent validity via robust positive

correlations with anxiety, depression and stress, and negative correlations with quality of

life and happiness. Criterion validity was supported by the finding that individuals who

reported employment loss or loss of income due to the pandemic, had experienced

COVID-19 infection in their household, or knew somebody personally who died from the

pandemic, had elevated scores on the PEIS.

 30

Parameter Limits for the Emotional Responses

To interpret the data, the following parametric scale will be used.

Scale Range of Scores Categorical Response Interpretation

5 4.21 - 5.00 Extremely Very High

4 3.41 - 4.20 A lot High

3 2.61 – 3.40 Moderately Moderate

2 1.81 – 2.60 A little bit Low

1 1.00 – 1.80 Not at all Very Low

The third part will utilize the validated instrument entitled, Protective Behaviors

towards COVID-19 Scale (PBCS) which is a 14-item scale from Google Scholar. It is

authored by Riad, Huang, Zheng, & Elavsky in 2020. Each item is scored on a Likert

scale of 5 points ranging from "Not at all like me" (1) to " Just like me" (5), with a total

score of 14-70. There were 5 items into the factor of routine protective behaviors (RPB),

6 items into post-exposure protective behaviors (PPB), and 3 items into post-exposure

risky behaviors (PRB). All factor loadings were greater than 0.4 and the fit of the CFA

model was acceptable (CFI=0.90, RMSEA=0.08, SRMR=0.06, chi-square/df=

179.15/74). The internal consistency of PBCS was good (Cronbach’s alpha = 0.85).
 31

Parameter Limits for the Self-Protective Behaviors

To interpret the data, the following parametric scale will be used.

Scale Range of Scores Categorical Response Interpretation

5 4.21 - 5.00 Just like me Always

4 3.41 - 4.20 Like me Often

3 2.61 – 3.40 Not Sure Sometimes

2 1.81 – 2.60 Not like me Very Rarely

1 1.00 – 1.80 Not at all like me Never

Research Procedures

The researchers will seek approval through a letter from Mrs. Merlyn A. Ouano,

Dean of the College of Health Sciences – Department of Nursing of the University of

Southern Philippines Foundation to conduct the study.

Furthermore, a transmittal letter will be sent to the Barangay Hall of Brgy. Luz

addressed to Hon. Renato S. Labrador, the barangay captain to ask permission to conduct

the study using the questionnaires.

The researchers will gather data using the adapted questionnaires. They will then

retrieve the answered questionnaires, tabulate the data for analysis, and the hypothesis

will be statistically treated for interpretation. The findings will serve as the basis for

concluding and recommending formulations.

 32

Ethical Considerations
In observance and support of the Data Privacy Law of the Philippines, the

researcher will make an effort to keep the participants’ identity and information

confidential. The researcher will ensure that all the participants are not to be placed in a

situation where they might be of risk of harm as a result of their participation either in

physical or psychological aspect. Rest assured integrity must be valued to protect the

privacy of the respondents.

Risk – Benefit Assessment

The researchers will assess the risk and benefits involved in the conduct of the

study as it is essential in protecting the interest of the participants.

Risk. One risk identified is the issue on disclosure of confidential

information of the participants. This will be addressed by assigning code to the research

tools. After gathering data and evidences, they will be destroyed.

Benefit. The output of the study will be more beneficial to the participants

and to the school and the output may be used to draft an enhanced program on inclusion.

Furthermore, their awareness on relevant concerns will help them improve the current

process on inclusion.

Content, Comprehension, and Documentation of Informed Consent

It is apparent that safeguarding the rights of the participants in this study should

be given with utmost importance. Thus, attached in this study is a sample of the informed

consent form indicating approval by the ethics committee which will be presented and

discussed to the participants before the conduct of the survey. It is implied that
 33

participation in this study is voluntary in nature and consent is given by the respondents

upon signifying their interest and agreement to participate.

Authorization to Access Private Information

Private information is authorized by the participants upon signing the consent

form. This signifies the responsibility of the researcher to safeguard this private

information upon its disclosure to the researcher or the adviser only. It is known to the

researcher and the participants that there may potential damage or risk to confidential

information that may arise. This should be effectively and confidentially dealt with by the

researcher.

Confidentiality Procedure

The following are the steps to be followed by the research to guarantee privacy:

(1) coding and distinguishing data; (2) maintaining a secured shelf for data storage

throughout the study; (3) entering no identifying information or mark in the instrument or

in the computer; and (4) destroying identifying information efficiently after use.

Debriefing, Communications and Referrals

Debriefing is the process of asking feedback at the end of the research process. It

is a dialogue between the researcher and the participants conducted in a way that benefits

and respects the respondents. In this study, the researcher will take time to explain the

importance of participating in the study and the expected outcome of participating. The

respondents will be debriefed after data gathering to avoid or minimize psychological

harm, if any. During the debriefing session, participants are urged to ask questions to
 34

further understand and clarify the purpose of the study and avoid confusion. In some

situations, it can be an avenue for new referrals to health, social, or psychological service.

Incentives or Compensation

It is important to note that there is no monetary incentive involved aside from a

simple token of appreciation for the participants who volunteer.

Conflict of Interest

The researcher/s will declare that there is no external funding for this study and

that all costs related to the conduct of this study are shouldered by the researcher/s. The

researchers are independent and are not affiliated to any organization. This study will be

carried out in partial fulfilment of the requirements for the degree Bachelor of Science in

Nursing.

Recruitment

The researcher/s will assure that there will be no coercion, intimidation, and

undue influence used in the selection and recruitment of participants and that they have

the right to refuse or withdraw at any time without fear of being penalized.

Vulnerability Assessment

The participants of this study should not belong to the vulnerable sector of the

society as they do not fit the characteristics of being vulnerable. Matters will be

addressed promptly and effectively if there is a threat of harm to the participants.

 35

Collaborative Study Terms of References

This study will be part of the academic requirement of the university and will be

undertaken solely by the researcher/s. The expenses incurred will be personally financed

by the researcher/s. This study can be published by any member of the team provided that

the member has been granted permission by the other members. The thesis adviser may

publish this study provided that the names of all the team members appear as co-authors.
 36

Statistical Analysis

The age, sex at birth, highest educational attainment, occupation, average

monthly income, and comorbidities of the respondents will be calculated using

frequency count and simple percentage.

1. Simple Percentage. This formula will be used to determine the profile of the

respondents.

P = f_ x 100
N

Where: P is the percentage

f is the frequency

N is the number of cases

The emotional responses of the respondents will be calculated using the

weighted mean because the instrument uses a 5-point likert scale.

The self-protective behaviors of the respondents will be calculated using

the weighted mean because the instrument uses a 5-point likert scale.
 37

2. Weighted Mean. This statistical tool will be used to determine the mean score of the

conducted survey.

ẋ = ∑ _fw_
N

Where:

ẋ is the weighted mean

f is the frequency

w is the weight of each item

N is the number of cases

3. T-test of Independent Variable. This will be used to compare the means of the two

variables in order to determine whether there is statistical evidence that the emotional

responses and self-protective behaviors of the respondents when grouped according to

age has a significant difference.

 38

4. Pearson r. This statistical tool will be used to test the relationship between emotional

responses and self-protective behaviors.

Where:

r = correlation coefficient

xi = values of the x-variable in a sample

𝑥̅ = mean of the values of the x-variable

yi = values of the y-variable in a sample

𝑦̅ = mean of the values of the y-variable

 39

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Appendix A

Ethics Informed Consent Form

University of Southern Philippines Foundation

Office of the Research Ethics Committee
Salinas Drive, Lahug, Cebu City

Ethics Informed Consent Form

Title of the study: Emotional Responses and Self-Protective Behaviours Among Adults
with Comorbidities During Covid-19 Pandemic

Name of the Researcher(s): Jade Catherine N. Matuguinas, Angel L. Revil, Louise

Faith M. Ruiz and Jessa Mae L. Tayo

Introduction
You are invited to participate in a research study conducted by Jade Catherine N.
(name of the
Matuguinas at the University of Southern Philippines because you fit the inclusion criteria
primary researcher)
as a participant of our study. Your participation is completely voluntary. Please read the
information below, and ask questions about anything you do not understand, before
deciding whether to participate. Please take as much time as you need to read the consent
form. You may also decide to discuss participation with your family and friends.
If you decide to participate, you will be asked to sign this form. You will be given
a copy of this form.

Purpose of the Study

This study aims to determine emotional responses and self-protective behaviours
among adults with comorbidities during COVID-19 pandemic in Barrio Luz, Cebu City
and to test the difference between the emotional responses and self-protective when
grouped according to age. Further, this study also aims to determine the significant
relationship between emotional responses and self-protective behaviour. The findings will
serve as bases for a proposed health intervention program for patients with comorbidities.
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Study Procedures
If you volunteer to participate in this study, you will be asked to participate by
answering the survey questionnaire which you can finish in fifteen (15) minutes to thirty
(30) minutes (duration).

Potential Risks and Discomforts

You may feel discomfort during the course of the interview because of the sensitive
nature of the topic being studied. You may opt not to answer questions which make you feel
any psychological or emotional distress or you can withdraw as a participant of the study
if you feel that you cannot discuss the information that is asked of you. The researchers
value your participation and will place your welfare as their highest priority during the
course of the study.

Potential Benefits to the Participants and/or to Society

This study can generate relevant information which can be useful to the participants
and to the school and the output may be used to draft an enhanced program on inclusion.
Furthermore, their awareness on relevant concerns will help them improve the current
process on inclusion.

Confidentiality
We will keep your records for this study confidential as far as permitted by law.
Any identifiable information obtained in connection with this study will remain
confidential, except, if necessary, to protect your privacy, rights and/or welfare. This
certificate means that the researcher can resist the release of information about your
participation to people who are not connected with the study. When the results of the
research are published or discussed in conferences, no identifiable information will be
used.

Participation and Withdrawal

Your participation is voluntary. Your refusal to participate will not involve penalty
or loss of benefits to which you are otherwise entitled. You may withdraw your consent at
any time and discontinue participation without penalty. You are not waiving any legal
claims, rights or remedies because of your participation in this research study.
 56

Investigator’s Contact Information

If you have any questions or concerns about the research, please feel free to contact
the researcher Jade Catherine N. Matuguinas at the USPF-College of Health Sciences –
Department of Nursing or through his/her mobile number 09509499566 through his/her
email address jadematuguinas@gmail.com if you need to see him/her, he/she can be
located at the UCMA Village, Apas, Cebu City.

Rights of the Research Participant

If you have questions, concerns, or complaints about your right as a research
participant or the research in general and are unable to contact the researcher(s), or if
you want to talk to someone independent of the research team, please contact the
University of Southern Philippines Foundation-Research Ethics Committee at (032) 414-
8773 and look for Dr. Odilon A. Maglasang.

Research Participant’s Consent

I have read the information provided above. I have been given a chance to
ask questions. My questions have been answered to my satisfaction, and I agree to
participate in this study. I have been given a copy of this form. I can withdraw my
consent at anytime and discontinue participation with-out penalty.

____________________________________ _____________________
Signature above Printed Name of Participant Date Signed

To be accomplished by the Researcher Obtaining Consent:

I have explained the research to the participant and answered all of his/her
questions. I believe that he/she understands the information described in this
document and freely consents to participate.
____________________________ ____________________
Name of PersonObtaining Consent Date Signed

Endorsed by/ Recommendedby: ___________________________

Research Adviser/ Mentor
Date Filed: ____________
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Appendix B

Research Instrument

Directions: Kindly accomplished the survey form from part I to Part III

Part I: DEMOGRAPHIC PROFILE

1. Age:

2. Sex at birth:

3. Highest educational attainment:

4. Occupation:

5. Average monthly income:

6. Comorbidities:

Part II: Pandemic Emotional Impact Scale

We would like to know the level of your emotional responses during the

pandemic. How much has your wellbeing and functioning been different in the following

ways during the pandemic compared to the way it was before when there was no

COVID-19 pandemic? For each of the following questions, please choose the number

that corresponds to the level of what you feel.

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Not A Moderately A Extremely

at little lot

all bit

(2) (3) (4) (5)

(1)

1. More worried about your

finances

2. More anxious or ill at ease

3. More difficulty concentrating

4. Being less productive

5. More worried about your

personal health and safety

6. Being more bored

7. More difficulty sleeping

8. Feeling more lonely or isolated

9. Feeling more down or

depressed

10. More worried about getting

necessities like groceries or

medications

11. More worried about the health

and safety of family members

or friends
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12. Feeling more frustrated about

not being able to do what you

usually enjoy doing

13. More worried about possible

breakdown of society

14. Feeling more angry or irritated

15. Feeling that the future seems

darker or scarier than before

16. Feeling more grief or sense of

loss

Part III: Protective Behaviors towards COVID-19 Scale (PBCS)

We would like to know the level of your self-protective behaviors during the

COVID-19 pandemic. For each of the following questions, please choose the number that

corresponds to the level of your protective behaviors.

1: Not at all like me, 2: Not like me, 3: Not Sure, 4: Like me, 5: Just like me.

1 I keep my hands clean during the outbreak. 1 2 3 4 5

2 I cancel various parties in the event of COVID-19 outbreak 1 2 3 4 5

immediately.

3 I cancel unnecessary travel plans in the event of COVID-19 1 2 3 4 5

outbreak immediately.

4 I do not visit any relatives or friends during the outbreak. 1 2 3 4 5

 60

5 I cover my mouth and nose whenever I go out or in public. 1 2 3 4 5

6 If I get in contact with someone from COVID-19 outbreak area, I 1 2 3 4 5

should isolate myself.

7 I shall report the health authorities if I have a family member 1 2 3 4 5

who just came from COVID-19 outbreak area.

8 If my family member or my friend is in health condition after 1 2 3 4 5

they come back from outbreak area, there is

no need to take protective measures.

9 In my opinion, quarantine can be terminated in advance if there 1 2 3 4 5

are no abnormal symptoms.

10 I should quarantine myself immediately if I have suspicious 1 2 3 4 5

symptoms.

11 I can take medicine without doctor’s suggestion as long my 1 2 3 4 5

suspicious are still mild.

12 If I have suspicious symptoms, I should try to get medical help 1 2 3 4 5

immediately from professional doctors.

13 Concealing medical history is not good for myself and others. 1 2 3 4 5

14 If there is a suspicious infection or a confirmed case at home, I 1 2 3 4 5

should notify the health authorities

as soon as possible.

Thank you for completing the questions!

Stay Safe!
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Curriculum Vitae
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