Introduction

Health care professionals the new coronavirus epidemic caused a sudden crisis in the world’s public health in late 2019, killing more than 838,000 people worldwide by August 30, 2020 [1]. The emergence of COVID-19 has changed people’s living conditions by causing travel restrictions, fear of transmission, fear of infection, fear of losing loved ones, closure of jobs and schools, and the devastating psychological effects of quarantine, such as depression, emotional changes, and individual and social anxiety [2]. In the meantime, nurses and health care workers are at the forefront of the fight against infectious diseases and COVID-19 and are more susceptible to the disease. The high mortality rate of hospitalized patients in COVID-19 wards, communication problems, lack of support, and lack of visiting time for COVID-19 patients have created a stressful condition for the nurses in coronavirus care wards [3]. Therefore, health professionals and in particular nurses often face a variety of stressful conditions in life, including the challenges of personal life, the nature of their job that requires a lot of standing and concentration, commitment to patient care, and working with patients that need help [4].

They are constantly exposed to various stressors that will have devastating effects on their job performance in the long run [5]. Murphy has defined job performance as a function of an individual’s performance in doing specific tasks, which includes a list of standard jobs [6]. The core of job performance depends on job demands, organizational goals and missions, and the organization’s beliefs about behaviors that are evaluated more frequently [7]. As far as nurses are concerned, job performance is defined as an effective factor in the ability to achieve occupational goals in accordance with job standards. As a powerful arm of the health care system and a solid pillar of patient care, nurses play an important role in care departments and affect every aspect of hospital performance. Job performance results from the combination three components: Expertise, effort, and the nature of working conditions [8]. Expertise refers to knowledge, ability, and scientific and professional competence of an employee in a particular field; effort includes a degree of internal and external motivation that makes a person excel in doing work; and the nature of working conditions includes a degree of compliance with the conditions in facilitating employee productivity [9].

In the case of nurses, job performance is defined as an effective factor in performing tasks and responsibilities related to direct patient care, and patient satisfaction and their mental and physical health are greatly affected by the performance of nurses [10]. The results of a study conducted in Urmia indicated that an increase in the effect of COVID-19 led to the decrease of the nurse’s job performance by 20% [11]. In this condition, health care providers caring for clients face daily situations that might have adverse effects on the quality of their care [4]. Given that psychological stress affects job performance, social support can act as a contributor to coping with stress, and this is more appropriate for nurses trying to improve their performance to a desired level [7]. Social support is defined as the actual or perceived useful behaviors available from others [12]. It can be considered as support that a person receives from family, friends, and the organization, and has a psychological dynamic that helps the person in emotional, physical, and cognitive aspects. Social support is studied as either perceived or received [13].

Perceived social support focuses on the individual’s cognitive assessment of his/her environment and his/her level of confidence that help and support will be available if required [14]. In the nursing profession, social support is considered as an occupational source. Social support from colleagues not only reduces negative effects of job stressors, but also guarantees that the work is done the best and the occupational goals will be achieved. In addition, social support from friends meets the person’s basic needs, such as the need to belong. Thus, social support is an incentive for work interaction through a motivational process [15]. Supportive work environments are the most important factor in creating job satisfaction for nurses, and enjoying social support affects patient treatment, employees’ job satisfaction, and recruitment and retention in the organization. Therefore, a work environment with a high level of social support will reduce job stress and retain the nurses in the organization [16].

Perceived social support is a combination of the three elements including emotion, acknowledgment, and help. Emotion means expressing love and affection; acknowledgment refers to the awareness of appropriate behaviors and feedbacks; and help means direct assistance in getting things done. Thus, one of the characteristics of the people relatively resistant to stressful events is having social support. Social support systems can mitigate negative effects of stress on mental health; therefore, having to support patients, nurses themselves need support systems [17]. Sarafino believes that social support from friends, family, and other people leads to reduced psychological stress in individuals and thus affects their mental health [18]. According to the theory of social support barrier-making, people enjoying high social support consider problems less stressful and may have a person or people who can provide solutions to their problems and give them encouragement and hope. Accordingly, social support can be used as a barrier to negative effects of stress and have an inverse relationship with the perception of stress and burnout [19]. Therefore, providing social support inside and outside the workplace can play an effective role in the health and well-being of nurses, improve employee productivity, and reduce stress in the face of challenges and problems [20]. A study of a group of nurses in the United States, the United Kingdom, and Canada found that perceived social support from co-workers increased job performance and reduced job stress in nurses [16].

Another effect of the spread of viral diseases, including COVID-19 that has affected the world at various levels, is stress and work pressure that causes dissatisfaction with the job and may lead to job burnout [11]. Job burnout is a psychological syndrome and a long-term response to chronic stress in the workplace. It was first described by Maslach, and its three main and distinct dimensions including exhaustion, depersonalization, and personal inadequacy were then introduced for job evaluation [21,22]. The results of a meta-analysis by Chemali et al., showed that the prevalence of job burnout among physicians, nurses, and other medical staff in the Middle East hospitals was about 40% to 60%. Job burnout is on the rise due to the high workload during the coronavirus pandemic [23,24].

Emotional exhaustion is considered as one of the components of job burnout. Nurses are known as one of the groups at risk of emotional exhaustion due to the nature, severity, and variety of the stressors associated with their professional tasks [25]. Emotional exhaustions are defined as the feeling of extremely lacking emotional and physical resources [26]. It is associated with the concepts of stress, anxiety, physical tiredness, insomnia [27]. Research has shown that job relationships that lack support and trust may increase the risk of burnout. When job relationships are positive and employees experience high levels of social support, job interactions improve as well. Besides, when individuals are supported by their workgroups, job resources (human resources, job capacities) are enriched, and job resources (capacities) can effectively reduce the prevalence of burnout [28]. Therefore, like useful information and emotional support, social support is an important source for employees to cope with daily stressors and thus improve their well-being [29].

Subjective well-being is another problem with nurse’s health. It is described as a set of experiences including emotional responses, satisfaction range, and overall judgment of life satisfaction, and deals with individual’s evaluation of their lives and mental measurement of satisfaction or dissatisfaction [30]. Subjective well-being is associated with positive and negative memories as well as emotional reactions to life events. It is in fact a term used to measure people’s satisfaction, happiness, and experience of quality of life. The experience includes cognitive and emotional perception and evaluation of life [31]. The emotional dimension refers to having positive emotions (pleasure, euphoria, happiness) and negative emotions (feelings of guilt, fear, anger) as well as emotions, and the cognitive dimension refers to a cognitive assessment of life satisfaction that measures a person’s positive emotions and excitement from different aspects of life [13]. Employees who are satisfied with their job and experience more positive emotions have a high level of subjective well-being. On the other hand, employees who do not have subjective well-being often suffer from job burnout. The importance of subjective well-being in an organization can be found out from positive results such as job performance, reduced absenteeism, and job satisfaction [32].

Social environments, including interpersonal relationships and social support from others, play a key role in shaping people’s prosperity and satisfaction with life. The results of a study showed that social support improved well-being by affecting emotions, cognitions, and behaviors in a way that it promoted positive effects [33]. Regarding what was stated above, it seems really important to address the factors affecting the performance of nurses, and since nursing is one of the highly important occupations in the society and nurses spend some part of their lives in close contact with patients, and due to the fact that optimal job performance guarantees the health and recovery of many patients in the community, identifying the factors affecting their performance and trying to promote such factors is of particular importance. Therefore, considering the everincreasing spread of the coronavirus and the excessive exhaustion of medical staff, the present study aimed to answer the question whether perceived social support and job performance had a relationship with the mediating role of emotional exhaustion and subjective well-being of nurses. The conceptual model of research is shown in Figure 1.

Figure 1. Conceptual model of research.

Materials and Methods

The present study is an applied descriptivecorrelational research. An electronic questionnaire was used to collect the information in this study. To this end, to this end, once the approval of the hospital’s ethics committees was obtained and coordination with the hospital authorities, the questionnaire was designed online and its link was provided to the people who were willing to participate in the study. The statistical population included all the nurses in Kerman hospitals in 2021. Five hospitals were randomly selected from among the public hospitals of Kerman. The sample size was considered 300 with regard to the number of the study variables, but due to possible drops, 21 more individuals (a total of 321 nurses) answered the research questions. The samples were selected through convenience sampling, and the data were analyzed using the path analysis method and the Amos 22 software. The following tools were also used to examine the variables. The data were analyzed using the structural equation modeling analysis and the AMOS statistical software. The tools for collecting information were as follows: (a) Subjective Well-being Scale, (b) Job Burnout Questionnaire, (c) Job Performance Questionnaire, (d) Perceived Social Support Questionnaire, and (e) a set of demographic questions included information about the nurses’ gender, education level, years in nursing profession, typical shift length, age, and so on.

Subjective well-being scale

Developed by Keyes and Magyar-Moe, this test was used to measure emotional, psychological, and social well-being [34]. It had 45 items and included 13 subscales. The first 12 questions dealt with emotional well-being, the next 18 ones were on psychological well-being, and the last 15 questions were about social well-being. The scale was scored on a Likert scale, with 12 items ranging from always (1) to never (5), and 33 items on a seven-point Likert scale from strongly disagree (1) to strongly agree (7). The scores ranged from 45 to 291. The internal validity of the emotional well-being subscale was 0.91 in the positive emotion section and 0.78 in the negative. The psychological and social well-being subscales had an average internal validity of 0.4 to 0.7, and the total validity of both subscales was ≥ 0.8 [34]. To evaluate the validity of this scale, factor validity had been used, and the results of confirmatory factor analysis confirmed the factor structure of this scale. In his study, Golestanibakht reported the reliability coefficient and reliability of the retest to be 0.86 [34]. The reliability of the subjective well-being scale and the emotional well-being, psychological well-being, and social well-being subscales was 0.75, 0.76, 0.64, and 0.76, respectively. The Cronbach’s alpha for the above-mentioned scale and subscales was 0.80 and 0.64, respectively, indicating the desired internal consistency of the scale [35].

Job burnout questionnaire

This scale was designed by Maslach and Jackson and contained 25 questions [36]. The scoring method was based on a 7-point Likert scale. The questionnaire had three dimensions, including emotional exhaustion, depersonalization, and feeling of inefficiency. Questions 1, 2, 3, 6, 8, 13, 14, 16, and 20 dealt with emotional exhaustion, questions 5, 10, 11, 15, and 22 were on depersonalization, and questions 4, 7, 12, 17, 18, 19, and 21 were on the feeling of inefficiency. The frequency and emotional exhaustion severity scores of >30 and >40, respectively, showed high emotional exhaustion; the frequency and emotional exhaustion severity scores of 18-29 and 26-39 indicated moderate emotional exhaustion; and frequency and emotional exhaustion severity scores of <17 and <25 showed mild emotional exhaustion. In this study, only the emotional exhaustion dimension was addressed. In addition, the test designers calculated the reliability and validity of the test using the Cronbach’s alpha of the internal consistency for the frequency of 0.83 and the intensity of 0.84. They also calculated the total reliability coefficient of the questionnaire for the frequency of 0.83 and the intensity of 0.53 [37]. The validity and reliability of this questionnaire in Iran have been determined in many studies by Iranian researchers and have been confirmed with scientific validity of >90%. To evaluate the face and content validity of this tool, Ghaniyoun got the approval of 10 managements, psychology, nursing, and emergency medicine lecturers and, using the Cronbach’s alpha, he obtained the reliability coefficient of 0.80 for emotional exhaustion, 0.81 for depersonalization, 0.84 for personal adequacy, and 0.83 for the whole questionnaire [38]. The results indicated the reliability of the whole questionnaire and its dimensions.

Job performance questionnaire

This test was designed and standardized by Patterson to be used to measure employee performance [39]. The test included 15 articles and 4 dimensions as follows: Observance of discipline, sense of responsibility at work, cooperation and teamwork spirit at work, and ability to continuously improve and correct things. The tool consisted of 15 questions on a four-point Likert scale (rarely, sometimes, often, and always) with a score range of 0 to 3, respectively. The range of the instrument scores was 0 to 45. The scores 0-11.25 indicated poor performance, 11.25-22.5 showed moderate performance, 22.5-33.75 indicated good performance, and 33.75-45 indicated excellent job performance. The reliability coefficients of this test had been reported by Arshadi and Piryaaee using the Cronbach’s alpha and halving methods as 0.82 and 0.85, respectively [40].

Perceived social support questionnaire

Providing a subjective assessment of social support adequacy, this scale was designed by Zimet et al., the questionnaire measured perceptions of social support adequacy in three sources: Family, friends, and important people in life [41]. The questionnaire consisted of 12 questions, each was graded on a seven-point scale from strongly disagree (1) to strongly agree (7). Based on the social support sources, each four questions were attributed to one of the factor groups including family (items 3, 4, 8, and 11), friends (items 6, 7, 9, and 12), and important people in life (items 1, 2, 5, and 10). It should be noted that in this scale, an increase in the individual’s scores led to the increase in their scores of perceived social support factor. Zimet et al., reported the Cronbach’s alpha coefficient of 0.81 to 0.98 in nonclinical samples and confirmed good validity of the scale [42]. In a preliminary study of psychometric properties of this scale in samples of Iranian students and general population (311 students, 431 others), Besharat et al., obtained the Cronbach’s alpha coefficients for the whole scale and the items of three subscales including family, important people, and friends to be 0.91, 0.87, 0.83, and 0.89, respectively [43]. In addition, the results of the exploratory and confirmatory factor analysis confirmed the validity of the multidimensional scale of perceived social support by determining three factors (social support, important people, and friends).

Results

Demographic information

A total of 321 nurses (119 males and 202 females) participated in this study. The mean age of the nurses was 31.31 and the standard deviation was 7.96. In terms of education levels, 9% had a lowerthan bachelor’s degree, 72.9% had a bachelor’s degree, 16.8% had a master’s degree, and 1.2% had a PhD. Regarding marital status, 142 nurses were single, 173 were married, and 6 were divorced. In addition, 25.2% of the nurses were conscription law’s conscript, 33% were permanent, 13.7% were corporate, 14.3% were temporary-topermanent, 4.7% were private contractual, and 8% were government contractual employees. In terms of income, 10.3% had incomes below 2 million tomans, 23.4% had incomes of 2 to 4 million tomans, 38.9% earned 4 to 6 million tomans, and 27.4% earned over 6 million tomans. Furthermore, 82.6% were working as medical staff but 17.4% were not medical staff. Finally, 85.7% had rotating shifts and 14.3% were on duty.

Descriptive indices among research variables

Table 1 shows the mean, standard deviation, maximum, and minimum scores of the participants based on the research variables. The results showed that the highest mean score was that of subjective well-being and the lowest was that of emotional exhaustion.

As shown in Table 2, there was a significant positive relationship between social support and subjective well-being variables and job performance. On the other hand, emotional exhaustion had a significant negative relationship with job performance. Emotional exhaustion had also a significant negative relationship with subjective well-being and social support (P<0.05).

Figure 2 shows the fitted research model. In order to evaluate the proposed model, the structural equations method was used in which all the indicators were in an acceptable range.

Figure 2. Final model of research.

According to Table 3, the normalized Chi-Square (CMIN/DF), Comparative Fit Index (CFI) is 0.945, Parsimony Normed Fit Index (PCFI) is 0.594, the Root Mean Square Error of Approximation (RMSEA) and the HOLTER were obtained 2.25. 0.945, 0.594, 0.067, and 205, respectively, showing that the model was highly fit.

Relationship between social support, job performance considering Emotional Exhaustion and subjective well-being in nursing

According to Table 4, social support in a multivariate environment was able to predict 0.304 of the job performance variance. Thus, the direct effect of social support on job performance was significant. Furthermore, social support was able to predict 0.523 of the subjective well-being variance, and the direct effect of social support on subjective well-being was significant (P<0.05). In addition, the standard effect of social support on emotional exhaustion was -0.447, the direct effect of which was significant. In other words, emotional exhaustion decreased with an increase in social support, (P<0.05). The direct effect of subjective well-being on job performance with the standard effect of 0.329 was statistically significant as well. Moreover, the direct effect of emotional exhaustion with the standard effect of -0.227 on job performance was statistically significant. The Sobel test was used to determine the significance of the mediating paths of subjective well-being and emotional exhaustion and the indirect effect of the independent variable on the dependent one. The results of the Sobel test confirmed the mediating roles of emotional exhaustion (P=0.000, Z=4.358) and subjective well-being (P=0.000, Z=4.112) in social support and job performance of the nurses. Therefore, the indirect effect of social support on job performance due to emotional exhaustion and subjective well-being was statistically significant.

Discussion

In this study According to the research findings, the direct impact of perceived social support was effective on job performance. The results of the statistical analysis showed that the overall and partial fit indices were all at appropriate levels, and the effect of the perceived social support on job performance was confirmed. In other words, the more the nurses perceived support from friends, family, and others, and believed that their presence and participation was valued and their well-being and success was taken into consideration, the greater their job performance would be. The results of this hypothesis are in line with the investigations of the relationship between perceived social support and job performance by Nasurdin et al., AbuAlRub, Kim et al., Wang et al., Amarneh et al., [7,16,29,44,45].

To explaining the results, it can be said that people with high levels of perceived social support are confident that others will be help them in times of need, and as a result, they may perceive potentially stressful events as less stressful. In fact, receiving multiple types of social support can help a person directly eliminate or at least reduce negative effects of potentially stressful situations and make nurses more competent in their job responsibilities. This will help improve their performance as well [44]. Thus, perceived social support leads to some kind of self-confidence and the assurance of an effective and beneficial response to COVID-19. Hence, job performance will improve in nurses with high perceived social support. In general, it should be stated that as one of the emotion-oriented coping methods, social support can protect people from stressful situations by preventing them from occurring, or help to assess stressful events in such a way that they get less threatening. It can also be provided in the form of psychological and emotional support or information support, tangible to ultimately increase the employee’s performance in the organization.

The results showed that perceived social support had a significant relationship with emotional exhaustion. In other words, an increase in social support would lead to decreased emotional exhaustion. This is consistent with the research of the studies by Ariapooran, Albar et al., Li et al., Ruisoto et al., [12,25-27].

To explain this finding, it can be said that social support has a protective role against stress, and since the continuation of stress may cause job burnout, social support will first reduce stress with its protective role and ultimately prevents the occurrence of job burnout. On the other hand, people with high social support feel more personal achievements, experience less stress and anxiety while working, underestimate the stress of different situations, assess their job more positively and productively, and evaluate their abilities to face work challenges more positive and efficient. These factors first increase their positive view of the job and job environment and finally reduce job burnout. In addition, social support allows individuals to develop positive social relationships with others and helps balance emotions and reduce burnout [26]. Thus, nurses with less supportive resources become vulnerable to emotional exhaustion. Therefore, social support is a useful and effective factor in improving nurses’ resilience and stress, especially to deal with emotional exhaustion.

The results also suggested that social support could predict the variance of subjective wellbeing, and the direct effect of perceived social support on subjective well-being was significant. This finding is consistent with the results of the research by Gulacti, Wang et al., Gallagher et al., [13,28,33].

It should be stated that high social support increases positive self-image, self-acceptance, and feelings of love and worth, while low social support reduces positive self-image and causes dissatisfaction in life. Social support also reduces negative effects of environmental stress and, consequently, increases the quality of life and life satisfaction. People with high social support feel that others care about them, love them, and support them at the time of difficulties. Such people have higher self-confidence, self-efficacy, and optimism, which increase their subjective wellbeing. Accordingly, Gulacti found in his research that family support could affect people’s cognitive patterns of subjective well-being [13]. In other words, positive relationships and family support led to positive emotional, social, and cognitive changes in children, and this was effective in portraying a more positive and satisfying life.

According to the results, emotional exhaustion mediated perceived social support and job performance in nurses. The is in line with the results of the studies by Taghilou et al., Ariapooran, Bayrami et al., Ruisoto et al., Halbesleben et al., [11,12,17,27,46].

To explain the results, it might be said that job stressors that lead to emotional exhaustion of nurses include high workload, long working hours, lack of support, and inability to leave work to rest. Job burnout in nurses who spend long hours at work is manifested in the form of feeling a lack of personal success in work life. Therefore, creating strong support systems inside and outside the workplace and trying to make a favorable work environment by providing full support to staff, reducing their workload, and increasing their freedom of action in decisionmaking can lead to reduced job burnout [17]. On the other hand, support from other people makes individuals more motivated, feel empowered, and as a result dedicate themselves more to work.

In fact, perceived support of nurses in family, friends, and colleagues plays an effective role as a barrier to prevent burnout and stress. Furthermore, given that low job performance is the result of emotional exhaustion, this feeling is known as a mediator of the relationship between perceived social support and job performance, because a person who finds more motivation to do his/her work through the support of those around him/ her becomes so obsessed with his/her work that she/he will not experience the inefficient feeling of emotional exhaustion. The nature and severity of stressors at hospitals have made nurses at high risk of emotional exhaustion. There is no doubt that job burnout reduces their efficiency and job performance, and this will be the starting point for their lack of motivation in paying attention to clients and performing their important task optimally and appropriately. Reduced stress and workload will lead to reduced job burnout as well [11]. A study by Ruisoto et al., indicated that emotional exhaustion, as the main dimension of job burnout, was the best predictor of general health in nurses, and social support could improve negative effects of emotional exhaustion in medical staff [27].

The findings also confirmed the subjective wellbeing mediated perceived social support and job performance in nurses. This is consistent with the results of the research by Kavoosi et al., Gulacti, Jia et al., Darvishmotevali et al., Mbatha, who identified the effects of subjective well-being on social support [10,13,21,31,32].

It can be acknowledged that social support helps nurse and healthcare providers withstand workload stress. Social support has a direct impact on negative consequences of such stimuli in different areas of life and reduces the levels of stress experienced. In fact, exposure to COVID-19 and systematically introduced quarantine procedures is more severe in places such as hospitals, health centers, and diagnostic units, and psychologically, such a condition has a profound effect on subjective well-being of the healthcare staff and thus changes their job performance. Therefore, nurses’ well-being and life satisfaction improve through perceiving social support from their families and managers, and this increases their performance and empowerment at workplace.

Conclusion

The results of the present study showed a significant positive relationship between perceived social support and emotional exhaustion of the nurses during COVID-19. There were also significant positive relationships between perceived social support and subjective wellbeing, between emotional exhaustion and job performance, and between subjective well-being and job performance of the nurses. Furthermore, perceived social support in nurses and attention to their needs were associated with high scores of their job performance. On the other hand, emotional exhaustion was associated with low scores of perceived social support, and subjective well-being was associated with high scores of perceived social supports.

Given that the present study was cross-sectional and examined the participants over a specific period of time, conclusion was a bit difficult, and the cause-and-effect relationships that perceived social support and the mediating variables of emotional burnout and subjective well-being had with job performance could not be found out. In addition, using a correlational research design made it more difficult to extract causal results. Besides, the only data collection tool used in this study was a questionnaire with a self-report nature that depended on the nurses’ feelings at the time of answering the questions. It is suggested that researchers interested in this field examine other psychological variables such as shift work, social capital dimensions, and psychological attributions in order to better identify the factors affecting job performance. In this study, a small sample was extracted from the research population and most of the subjects were female. However, the ratio of male and female nurses to their actual ratio in society was observed in the present research. Due to the urgency of the conditions, the researchers collected the data through online methods that could influence the results. In addition, the respondents’ psychological stress could affect their responses. In general, this is the first study conducted in the Iranian society to address the concepts of emotional exhaustion and subjective well-being as the factors affecting job performance. Future studies are better to try to replicate these results in larger samples and use longitudinal and experimental designs to prove or disprove research hypotheses. They are also suggested to include the role of depression, anxiety, and stress in the medical staff dealing with COVID-19 over a longer period of time in order to provide appropriate psychological services to help those under severe stress due to the pandemic.

Other studies such as qualitative ones in this field are also recommended to reveal more aspects of this phenomenon.

Declarations

Ethics approval and consent to participate

IEthical approval was not required for this research article and any discussion is fully anonymised. All the participants were informed about the objectives of the Study and the voluntary nature of their participation. The questionnaires did not include names or other ways of personal identification of the participants to keep the protection of privacy and maintenance of confidentiality. Informed consent was obtained from each participant.

Consent for publication

Not applicable.

Availability of data and materials

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

Competing interests

Not applicable

Funding

Not applicable

Authors’ contributions

SHM, AS, SK, PA conceived and designed the study, conducted research, provided research materials, and collected and organized data. SHM, AS, SK, PA analyzed and interpreted data. SHM, AS wrote initial and final draft of article, and provided logistic support. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Acknowledgements

We would like to thank all the individuals who participated in the study.

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Citation: Mediating Role of Emotional Exhaustion and Subjective Well-Being in the Relationship between Perceived Social Support and Job Performance of Nurses during the Corona Pandemic ASEAN Journal of Psychiatry, Vol. 25 (5) May, 2024; 1-12.