EDUCATIO : Journal Of Education Volume 8 , Number 1, May 2023 ISSN : 2579-8383 (Print) ISSN : 2579-8405 (Online) zzzzzz z Correlational Analysis of Academic Motivational and Amotivational Approach among Education Students during Covid-19 Pandemic Agnes M. Aquino Professor, Holy Cross College, Sta. Rosa, NE, Inc., Philippines Email: aquinoagnes@holycross.edu.ph Accepted: Feb 10th 2023 Reviewed: April 5th 2023 Published: May 30th 2023 Abstract: This research aims to determine the motivation of the students to study in the College and if the recent Covid-19 social distancing measures motivate them to continue. This study will also measure the amotivation level of the respondents in relation to Covid-19 pandemic learning experiences. Using descriptive correlational design which involves the systematic investigation of the nature of relationships between and among variables, the relationships of profile, academic motivation and amotivation of the respondents were explored. Following the analysis of data, respondents agreed about their motivation preference since the Covid-19 social distancing measures were put in place. Almost half of the respondents support the feelings of competence such as more teacher/student engagement, face-to-face meetings and provide action plans for academic future. Additionally, The respondents had academic motivational in terms of Striving for Excellence, Desire to Learn, and Personal Incentives. However, the respondents still experienced amotivation prior to Covid-19 pandemic. With this in line, the respondents are recommended to be given with sharing and learning activities to help them improve significantly their well-being regarding motivation to success in education. Keyword: Striving for Excellence, Desire to Learn, Personal Incentives, Introduction The global pandemic of Corona Virus Disease (Covid-19) afflicted the majority of individuals, including those in the Philippines. On March 11, 2020, the World Health Organization declared Covid-19 a global pandemic, which is why all universities around the world switched to online teaching to reduce the virus spread. Holy Cross College is one of the schools in the country that has adapted to the changing educational environment as a result of the pandemic. For the institution to comply with CHED Memorandum Order No.04, Series of 2020 about the Guidelines on the Implementation of Flexible Learning in Public and Private Higher Education Institutions (HEIs). As a result, one of the adaptive steps for teachers and students to continue teaching and learning is to use Online Learning Management because of its user-friendly mode and creative software specs, this learning management system is designed to facilitate teaching and learning. According to Tria, technology is required for the integration of subject courses1. In terms 1 Jose Z Tria, “The COVID-19 Pandemic through the Lens of Education in the Philippines: The New Normal,” International Journal of Pedagogical Development and Lifelong Learning 1, no. 1 (2020): ep2001, http://dx.doi.org/10.30935/ijpdll/8311. mailto:riyu.choirul57@gmail.com Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 36 zzzzzz of teaching and learning motivation has a positive impact on the development of process skills and the ability to solve real-world problems. Furthermore, Vollbrecht, Porter-Stransky, & Lackey-Cornelison showed that students with a critical thinking skills background have greater systematic ability. Solving real-world problems aligned with technology are also important components in allowing students to understand the lessons and get motivated fully. A number of applied learning experiences have been linked to higher levels of learning2. In relation, Trolian et.al., proved that academic motivation can include things like applying concepts to real-world problems or novel situations, taking exams or assignments that require you to use course content to solve a problem, conducting research with a professor, and participating in extracurricular activities that help you put what you've learned in class into practice3. Applied learning approaches enhance students' motivation as academic motivation declines during college. Methods and tactics for designing and executing applied learning experiences in the classroom and outside of the classroom should be considered by higher education institutions. Meanwhile, Tus 4 mentioned multiple factors influence academic success which stress and motivation are two of these elements and this is a crucial factor to consider because a superior academic record leads to a better job opportunity. In life's opportunities existing circumstances the motivation and stress ideas can be found in a wide range of courses from the Philippines and Asia. Moreover, Hidajat et.al., 5 proved that the desire to be actively involved in lectures is active behavior such as listening to forums, explaining arguments, asking questions, and solving problems. This active behavior can be measured using operational scales and observational rubrics and determination to survive when faced with challenges are all indicators of students' academic motivation with challenges and issues, as well as the desire to get up and try again after failing. Boredom and lethargy in attending lectures, passive attendance at lectures, and a high rate of absenteeism and dropout are all indicators of students who are lacking in motivation. As individuals developed a closer fit between their interests and new accessible possibilities, it was expected that amotivation would decrease and motivation would increase during both transitions. According to previous data, young people who viewed their main task as a way of achieving their career goals and independent living 6 considered it to be more difficult to achieve their goals. A better match between their talents and interests and the new work or academic setting 7. 2 Peter J Vollbrecht, Kirsten A Porter-Stransky, and Wendy L Lackey-Cornelison, “Lessons Learned While Creating an Effective Emergency Remote Learning Environment for Students during the COVID-19 Pandemic,” Advances in physiology education 44, no. 4 (December 1, 2020): 722–725, https://pubmed.ncbi.nlm.nih.gov/33141599. 3 Teniell L Trolian and Elizabeth A Jach, “Engagement in College and University Applied Learning Experiences and Students’ Academic Motivation,” Journal of Experiential Education 43, no. 3 (2020): 317–335, http://dx.doi.org/10.1177/1053825920925100. 4 Jhoselle Tus, “Academic Stress, Academic Motivation, and Its Relationship on the Academic Performance of the Senior High School Students,” Asian Journal of Multidisciplinary Studies 8, no. 11 (2020): 29–37. 5 Helga Graciani Hidajat et al., “Why I’m Bored in Learning? Exploration of Students’ Academic Motivation,” International Journal of Instruction 13, no. 3 (2020): 119–136, http://dx.doi.org/10.29333/iji.2020.1339a. 6 Robert W Lent and Steven D Brown, “Social Cognitive Model of Career Self-Management: Toward a Unifying View of Adaptive Career Behavior across the Life Span.,” Journal of Counseling Psychology 60, no. 4 (2013): 557–568, http://dx.doi.org/10.1037/a0033446. 7 Jennifer Symonds et al., “The Development of Motivation and Amotivation to Study and Work across Age- Graded Transitions in Adolescence and Young Adulthood,” Journal of Youth and Adolescence 48, no. 6 (2019): 1131– Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 37 zzzzzz Furthermore, given that these tracks are found to impact study burnout such as feelings of apathy, cynicism, and inadequacy, engagement, and educational aspirations in Finland, the rate of change was expected to be moderated by the track young people took at the end of schooling8. Hence, this research is anchored from the Attribution Theory of Weiner in 1986 which is concerned about the process of individuals in interpreting events in relation to their behavior and thinking. This research will consider the 3-stage processes focusing on the 1) perception and observation of behavior; 2) belief that behavior is intentionally performed; and 3) person must determine if they believe the other person was forced to conduct the said behavior may it be attributed to situation or other person. This research will determine the motivation of the students to study in the College and if the recent Covid-19 social distancing measures motivate them to continue. This study will also measure the amotivation level of the respondents in relation to Covid-19 pandemic learning experiences. Literature Review This research was anchored from the Attribution Theory of Weiner in 1986 which was concerned about the process of individuals in interpreting events in relation to their behavior and thinking. This research considered the 3-stage processes focusing on the 1) perception and observation of behavior; 2) belief that behavior is intentionally performed; and 3) person must determine if they believe the other person was forced to conduct the said behavior may it be attributed to situation or other person. In connection, this research determined the academic motivation of the students to study in college including the recent Covid-19 social distancing measures that motivate them to continue. Fig. 1 - Research Paradigm on the Academic Motivational and Amotivational Approach Methods This research utilized a descriptive correlational design which involves the systematic 1145, http://dx.doi.org/10.1007/s10964-019-01003-4. 8 Symonds et al., “The Development of Motivation and Amotivation to Study and Work across Age-Graded Transitions in Adolescence and Young Adulthood.” Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 38 zzzzzz investigation of the nature of relationships between and among variables 9. The involvement of cross-sectional to examine if changes in one or more variables are directly in relation to changes in another variable will be considered in this research. The relationships of profile, academic motivation and amotivation of the respondents are the specific variables that will be explored in this study. The respondents of this research were Education students of Holy Cross College. Non- probability sampling specifically purposive sampling was utilized in this study which was focused on the inclusion criteria considerations of selecting the participants. This research also considered the profile, academic motivation and amotivation of the College students in this time of Covid-19 pandemic. The conduct of this research began during the first semester of S. Y. 2021 – 2022. The inclusion criteria considered in this research were 1) college students; 2) year level 1 to 4; and lastly, 3) regular students. This research utilized a modified version of the research instrument adapted from the study of Nijiru focusing on the following: Part I. Profile of the Respondents focusing on age, sex, course and year level of the respondents. Part II. Academic Motivation of the respondents concentrating on: • Striving for Excellence pertaining to goals, tasks, effort, values, ability • Desire to Learn relating to interest, learning from others, responsibility for learning • Personal Incentives linking to extrinsic rewards, intrinsic rewards, social rewards Part III. Amotivation prior to Covid-19 pandemic focusing on the reasons of the respondents in continuing College courses amidst Covid-19 pandemic. The Cronbach Alpha score of the research instrument was .92. The likert scale and description are as follows: 3.51 – 4.00 = In all of my subjects 2.51 – 3.50 = In most of my subjects 1.51 – 2.50 = In some (few) of my subjects 1.00 – 1.50 = In none or only one of my subjects The researcher secured a permit from the Vice President for Academic Affairs and College deans of Holy Cross College. After securing the approved request letter, the researcher did the encoding of the research instrument using google form app. After accomplishing the encoding and validation process among the pre-testing-respondents, the data was sent to the statistician for the computation of Cronbach Alpha score. As the research instrument attained passing reliability score the actual data gathering procedure proceeded among the actual respondents of this research using google form app also. Upon completion of the data gathering the data was analyzed, interpreted and discussed to provide the overall illustration of the findings in tables and figures. This research assured that the Covid-19 Inter-Agency Task Force Protocols was strictly followed to ensure the safety of the respondents. Result And Discussion 9 Larry B Christensen et al., “Research Methods, Design, and Analysis” (2011). Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 39 zzzzzz Table 1 - Distribution of Profile of the Respondents According to Age Age Frequency Percent 0 1 .5 18 24 11.8 19 51 25.0 20 60 29.4 21 25 12.3 22 16 7.8 23 5 2.5 24 2 1.0 25 3 1.5 26 3 1.5 27 1 .5 28 4 2.0 29 2 1.0 30 4 2.0 33 1 .5 34 1 .5 36 1 .5 Total 204 100.0 The common age of the respondents are 20 with a frequency 60 and a percentage of 29.4 meanwhile, 51 of the respondents are 19 years old with a percentage of 25. Fig. 2 - Distribution of Respondents According to Sex The biggest distribution of the respondents based on sex was female (86.3%) while males were only 13.7%. Table 2 - Distribution of Profile of the Respondents According to Course Program Frequency Percent Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 40 zzzzzz BEED 146 71.6 BSED 58 28.4 Total 204 100.0 Majority of the respondents belonged to Bachelor of Elementary Education with a 146 frequency and a 71.6 percent while Bachelor of Science in Education were 58 and 28.4 percent. Fig. 3 - Distribution of Respondents According to Year Level In terms of year level there were 35.8 percent of the respondents who belonged to Third year, 35.3 percent were into First Year and 27 percent belonged to Second Year. Fig. 4 - Motivation Preference of the Respondents Since the Covid-19 Social Distancing Measures Were Put In Place Majority of the respondents answered Yes (65.7%) while some said No (24.2%) about their motivation preference since the Covid-19 social distancing measures were put in place. Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 41 zzzzzz Fig. 5 - Preference to Thinking If College Can Do Better To Help with Motivation Levels Almost half of the respondents support the feelings of competence such as more teacher/student engagement, face-to-face meetings and provide action plans for academic future (46.6%), meanwhile, 28.4 percent prefer the provision of more autonomy in lecture, schedules, more classes, online content options, ability to study at a distance. Academic Motivational Approach of Education Students The academic motivational approach of education students is illustrated in Table 3 below. Table 3 – Academic Motivation Approach Academic Motivation Weighted Mean Striving for Excellence Standards I study hard as much as I can 3.66 I think about what I want to attain in my studies 3.61 I set for myself high scores which I believe I can achieve 3.49 Total 3.59 Goals I try different ways to solve academic problems 3.50 I set realistic and challenging academic goals 3.51 I set highest academic goals which I can achieve 3.50 When I don’t get what I expect in my studies, I work hard so that I may achieve my goals 3.58 If I do not attain my goals, I try again and again 3.66 Total 3.55 Tasks I do study outside class homework 3.17 I just aim to complete homework 3.62 I try to do all studies which I think I might succeed 3.64 I try to do most studies which I think I might succeed 3.60 I only choose the easy study work which I think I will succeed 3.16 Total 3.44 Effort I make strong demand on myself to pass in my studies 3.55 I struggle hard to get correct answers in homework given 3.23 Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 42 zzzzzz I check my work carefully so that I can get good marks 3.70 I prepare myself to get high marks in my studies 3.58 I make string effort to achieve as high mar as I can 3.67 Total 3.55 Values When I have no enough time for studies, I think about the importance of education 3.65 I value achievement in studies 3.77 Total 3.71 Ability I have confidence that I can pass in my studies 3.62 I receive encouragement on my studies from my teachers 3.52 I receive encouragement from at least one friend on my ability in my studies 3.51 I receive encouragement from at least one of my parents on my ability in studies 3.61 Total 3.57 Desire to Learn Interest I show genuine interest in learning 3.58 I show interest in the subjects I take 3.60 I read and research widely on different topics 3.37 I get interested in solving problems that others have as well in a topic 3.37 I show interest about topics being taught 3.59 I concentrate in my academic work 3.60 Total 3.52 Learning from others I participate in classroom discussions 3.50 I participate in small group discussion 3.45 I ask questions on topics I do not understand from others 3.20 I try to learn from others who are better in studies than me 3.43 I seek help from experts in my studies 3.30 I pay attention to my teachers to understand what is being taught 3.66 Total 3.42 Responsibility for Learning I take my studies as a personal responsibility 3.76 I struggle to gather information on topics so that I can master them 3.43 Total 3.60 Personal Incentives Extrinsic Rewards I like the rewards that studies bring 3.51 I try to work hard because doing well in studies brings high status 3.55 I like to study in order to be the winner in my class 2.91 Total 3.32 Intrinsic Rewards I like studies because we interact with friends while we study 3.44 I try to work hard in studies because of the challenges it brings 3.50 I like the intellectual challenge brought about by academic work 3.46 I like to solve problems in studies 3.30 Total 3.43 Social Rewards I like the social relationships involved in studies 3.41 I have fun with peers as we study 3.46 I get honor and praise from my family for passing in my studies or exams 3.47 I get honor and praise from teachers for passing in my studies/exams 3.34 Total 3.42 Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 43 zzzzzz The academic motivational approach of education students in terms of Striving for Excellence which had a verbal description of “In all of my subjects” and a total weighted mean were Standards (3.59); Goals; Effort (3.55); Values (3.71); Ability (3.57); however, in terms of Tasks (3.44) had a verbal description of “In most of my subjects”. In terms of Standards, the respondents answered that in “In all of my subjects” (3.66) they study hard as much as they can and they think about what they want to attain in their studies (3.61). With regard to Goals the respondents answered that “In all of my subjects” if they did not attain their goals, they will try again and again (3.66) and when they did not get what they expect in their studies, they work hard so that they may achieve their goals (3.58). As regard to Tasks the respondents also answered “In all of my subjects” they try to do all studies which they thought they might succeed (3.64) and they just aim to complete their homework (3.62). Regarding Effort the respondents responded “In all of my subjects” that they check their work carefully so that they can get good marks (3.70) and they make string effort to achieve as high mark as they can (3.67). Moreover, concerning Values the respondents replied “In all of my subjects” they have confidence that they can pass in their studies (3.62) and they receive encouragement from at least one of their parents on their ability in their studies (3.61). The total weighted mean of the responses of the respondents’ Desire to Learn in terms of Interest (3.52); Responsibility of Learning (3.60) had a verbal description of “In all of my subjects” although, Learning from Others had a total weighted mean of 3.42 with a verbal description of “In most of my subjects”. In terms of Interest the respondents responded “In all of my subjects” that they were concentrated in their academic work likewise they showed interest in the subjects they took (3.60) and they showed interest about the topics being taught (3.59). As to Learning from Others they replied “In most of my subjects” that they pay attention to the teachers to understand what was being taught (3.66) likewise they participated in classroom discussions (3.50). Their responsibility for learning response was “In most of my subjects” which they took their studies as a personal responsibility (3.76) and they struggled to gather information on topics so that they could master them (3.43). In terms of Personal Incentives, the total weighted mean was Extrinsic Rewards (3.32) whereas Intrinsic Rewards (3.43) with a verbal description of “In most of my subjects”. With regard to Extrinsic Rewards the respondents replied “In all of my subjects” that they ried to work hard because doing well in studies brings high status (3.55) and they liked the rewards that studies bring (3.51). Intrinsic Rewards the respondents responded that “In most of my subjects” they tried to work hard in studies because of the challenges it brings (3.50). also, they liked the intellectual challenge brought about by academic work (3.46). Lastly, concerning Social Rewards, the total weighted mean was 3.42 with a verbal description of “In most of my subjects”. The respondents answered “In most of my subjects” that they got honor and praise from their family for passing in their studies or exams (3.47) and they have fun with peers as they study (3.46). Amotivation Prior to Covid -19 Pandemic Table 4 shows the amotivational prior to Covid-19 pandemic of education students. Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 44 zzzzzz Table 4 – Academic Motivation Approach Amotivation Weighted Mean I really feel that I am wasting my time in college 1.72 I once had a good reason for studying for college however I wonder whether I should continue 2.59 I cannot see why I go to college and frankly, I could not care less 1.85 I cannot understand what I am doing in college 1.83 I cannot appreciate the lessons in college 1.70 I feel lazy attending my class 1.87 I am always late in submitting my tasks 1.70 I just check the requirements and do nothing 1.80 I cannot persuade myself in attending classes 1.67 Total 1.86 The total weighted mean of the responses of the respondents for the amoitvation prior to Covid-19 pandemic of the students was 1.86 with a verbal description of In some (few) of my subjects. Correlation between the profile and academic motivation of the respondents Table 5 illustrates the significant relationship between the profile and academic motivation of the respondents. Table 5 – Correlation between the Profile And Academic Motivation Of The Respondents Academic Motivation Interpretation Age Pearson Correlation .042 Not Significant Sex Pearson Correlation -.009 Not Significant Course Pearson Correlation .086 Not Significant Year Level Pearson Correlation .150* Significant *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Result show that only year level had significant correlation to academic motivation with an r - value of .150* and interpreted as Significant at 0.05 level of significance. It implies that higher year level of students are more motivated than their lower year counterparts. Correlation between the profile and amotivation of the respondents The significant relationship between the profile and amotivation of the respondents is shown in Table 6. Table 6 – Correlation between the Profile and Amotivation Of The Respondents Amotivation Interpretation Age Pearson Correlation -.094 Not Significant Sex Pearson Correlation -.058 Not Significant Course Pearson Correlation -.021 Not Significant Year Level Pearson Correlation -.101 Not Significant Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 45 zzzzzz *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Data show that all the findings were not significant. The age, sex, course, and year level of the respondents are not indicators of the amotivation that they experiences. Correlation between the academic motivation and amotivation of the respondents The significant relationship between the academic motivation and amotivation of the respondents is shown in Table 7. Table 7 – Correlation between the Academic Motivation and Amotivation of the Respondents Correlations Academic Motivation Amotivation Interpretation Academic Motivation Pearson Correlation 1 -.088 Not Significant Amotivation Pearson Correlation -.088 1 Not Significant *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Findings revealed that there was no significant correlation between academic motivation and amotivation. It means that students can be both motivated and amotivated at the same time. Conclusion This research further concludes the following statements in relation to the results of this research. 1. The respondents belonged to teen and adult age classification mostly female, and belonged to Bachelor of Elementary Education in 3rd year level who agreed about their motivation preference since the Covid-19 social distancing measures were put in place. Almost half of the respondents support the feelings of competence such as more teacher/student engagement, face-to-face meetings and provide action plans for academic future. 2. The respondents had academic motivational in terms of Striving for Excellence, Desire to Learn, and Personal Incentives. 3. The respondents experienced amotivation prior to Covid-19 pandemic. 4. Result show that only year level had significant correlation to academic motivation at 0.05 level of significance. 5. There was no significant correlation between academic motivation and amotivation. Recommendations Yuli Choirul Ummah Dismantling Paradigm Book Ta'limul Muta'allim Volume 1, Number 2, November 2016 | 46 zzzzzz This research further recommends the following statements in relation to the conclusion of this research. 1. Other courses and discipline may be considered as respondents to the next parallel study of this research. 2. The sense of academic motivation in terms of Striving for Excellence, Desire to Learn, and Personal Incentives among future respondents may be considered to assess better plans for academic success. 3. The respondents may be given sharing and learning activities to help them improve significantly their well-being regarding motivation to success in education. 4. Provision of more learning materials for their academic success is encourage. 5. This further recommends the continuity of learning academically among learners. 6. Future research may be recommended to determine the specific reasons of academic motivation and amotivation in relation to learning enabling technology. References Christensen, Larry B, Burke Johnson, Lisa Anne Turner, and Larry B Christensen. “Research Methods, Design, and Analysis” (2011). Hidajat, Helga Graciani, Fattah Hanurawan, Tutut Chusniyah, and Hetti Rahmawati. “Why I’m Bored in Learning? Exploration of Students’ Academic Motivation.” International Journal of Instruction 13, no. 3 (2020): 119–136. http://dx.doi.org/10.29333/iji.2020.1339a. Lent, Robert W, and Steven D Brown. “Social Cognitive Model of Career Self-Management: Toward a Unifying View of Adaptive Career Behavior across the Life Span.” Journal of Counseling Psychology 60, no. 4 (2013): 557–568. http://dx.doi.org/10.1037/a0033446. Symonds, Jennifer, Ingrid Schoon, Jacquelynne Eccles, and Katariina Salmela-Aro. “The Development of Motivation and Amotivation to Study and Work across Age-Graded Transitions in Adolescence and Young Adulthood.” Journal of Youth and Adolescence 48, no. 6 (2019): 1131–1145. http://dx.doi.org/10.1007/s10964-019-01003-4. Tria, Jose Z. “The COVID-19 Pandemic through the Lens of Education in the Philippines: The New Normal.” International Journal of Pedagogical Development and Lifelong Learning 1, no. 1 (2020): ep2001. http://dx.doi.org/10.30935/ijpdll/8311. Trolian, Teniell L, and Elizabeth A Jach. “Engagement in College and University Applied Learning Experiences and Students’ Academic Motivation.” Journal of Experiential Education 43, no. 3 (2020): 317–335. http://dx.doi.org/10.1177/1053825920925100. Tus, Jhoselle. “Academic Stress, Academic Motivation, and Its Relationship on the Academic Performance of the Senior High School Students.” Asian Journal of Multidisciplinary Studies 8, no. 11 (2020): 29–37. Vollbrecht, Peter J, Kirsten A Porter-Stransky, and Wendy L Lackey-Cornelison. “Lessons Learned While Creating an Effective Emergency Remote Learning Environment for Students during the COVID-19 Pandemic.” Advances in physiology education 44, no. 4 (December 1, 2020): 722–725. https://pubmed.ncbi.nlm.nih.gov/33141599.