*4.3. The Non-Significant Mediating Effect of Confidence on the Association between Perceived Social Support and Active Coping with COVID-19*

We found that perceived social support was positively associated with confidence, whereas the association between confidence and coping with COVID-19 was not significant. A cross-sectional observational study on medical staff treating patients with COVID-19 in China demonstrated that levels of social support were significantly associated with selfefficacy [38]. Self-efficacy represents how well one can execute courses of action required to deal with prospective situations, and indicates an individual's belief that they can overcome obstacles [39]. Although confidence against COVID-19 cannot be entirely compared with self-efficacy, the association between perceived social support and confidence observed in the current study deserves further investigation to explore the potential effect of social support on self-efficacy.

On the other hand, the insignificant association between confidence and active coping with COVID-19 means that confidence failed to significantly mediate the association between perceived social support and active coping with COVID-19. Since previous studies have emphasized the significant association between gathering information and confidence [22,40], gathering information was only considered as part of active coping with COVID-19 in the current study. This unexpected finding violated the hypothesis of the current study. Several factors may implicate this insignificant association. First, it is possible that other factors involved in active coping with COVID-19 interfered with the association. On the other hand, the questionnaires of confidence in the current study may be insufficient to entirely measure the self-efficacy of participants. Therefore, further development of conceptual model with comprehensively psychological factors and detailed questionnaires measuring self-efficacy may be helpful to determine the detailed interactions between confidence and coping strategies against COVID-19.

#### *4.4. Limitations*

There are several limitations to the present study. First, possible selection bias may have confounded the results, as the participants were only recruited through a Facebook advertisement. Second, causality could only be inferred among the variables due to the cross-sectional design of this study. Third, several measurements which were crucial in this scenario were not estimated in the questionnaires, such as level of stigma [16], psychological distress, and symptoms of post-traumatic stress disorder (PTSD). Finally, COVID-19 had a limited impact in Taiwan in comparison with other countries, so whether our results can be generalized to other countries is unclear and warrants further investigation.

#### **5. Conclusions**

In the present study, we found that lower perceived social support was indirectly associated with increased active coping against COVID-19, and that this association was mediated by higher risk perception. However, we did not identify a mediating effect of confidence or a direct effect between perceived social support and active coping with COVID-19. The implication of the current study is that intervention to enhance both perceived social support and risk perception are necessary for public during COVID-19 pandemic. Moreover, risk perception could be more effective to enhance active coping with COVID-19 than the confidence against COVID-19. The subjects who were satisfied with their social support might have had optimism bias that weakened their risk perception and had a compromising effect on their motivation to cope with COVID-19. Since the inversed association between perceived social support and risk perception, it is critical to reduce the effect of optimism bias resulting from perceived social support but not reduce the social support. To enhance perceived social support, specific resources to facilitate social interaction are warranted under adequate infection control. Regarding the impact of the problematic internet use, it is still necessary to promote the telecommunication, online gathering, or programs of social interaction at the difficult time of social distancing. In order to strengthen the risk perception and weaken the effect of optimism bias, facilitation of individuals' recognition to this pandemic may be beneficial. Timely and correct information about current threats, policies, and strategies against COVID-19 are necessary and should be announced by the authorities through traditional (newspapers or television news) and digital media, such as news feed or livestream thought social software. Public education on infection control is also necessary both during infectious disease outbreaks and at other times.

We have several suggestions for further research, which could help extend the findings of the present study. A paper-and-pencil questionnaire as opposed to a digital questionnaire, along with printed advertisements posted in public areas would be beneficial to also include non-netizens in the study population. Additional psycho-social factors should also be considered, such as stigma, discrimination, psychological distress, and symptoms of post-traumatic stress disorder. Moreover, further studies investigating optimism bias and self-efficacy using the General Self-Efficacy Scale [41] may be helpful to explore how people cope with the threats of COVID-19. Finally, the prospective cohort study estimating the self-efficacy, risk perception, coping with COVID-19, perceived support and related psycho-social factors (stigma, discrimination, symptoms of PTSD, psychological distress, vaccine hesitancy, etc.) at different stages of this pandemic are warranted. Importantly, attitude or hesitancy of vaccine may be associated with risk perception or coping with COVID-19. Measurements at different stages will be helpful to verify the conceptual model.

**Author Contributions:** D.-J.L.: Conceptualization, methodology, formal analysis, investigation, writing—original draft. N.-Y.K.: Formal analysis, data curation, conceptualization. Y.-P.C.: Methodology, data curation. C.-F.Y.: Conceptualization, methodology, formal analysis, project administration, writing—review and editing. Y.-L.C.: Formal analysis, writing—review and editing. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** This study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (approval no. KMUHIRB-EXEMPT(I)20200011).

**Informed Consent Statement:** Patient consent was waived due to the design of on-line survey. Participation in the online survey was voluntary and survey responses were anonymous.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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