research title qualitative about covid 19

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Open Access

Peer-reviewed

Research Article

The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study

Contributed equally to this work with: Dominika Maison, Diana Jaworska, Dominika Adamczyk, Daria Affeltowicz

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Affiliation Faculty of Psychology, University of Warsaw, Warsaw, Poland

Roles Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Conceptualization, Formal analysis, Investigation, Methodology

• Dominika Maison, 
• Diana Jaworska, 
• Dominika Adamczyk, 
• Daria Affeltowicz

• Published: October 11, 2021
• https://doi.org/10.1371/journal.pone.0258133
• Peer Review
• Reader Comments

The conducted qualitative research was aimed at capturing the biggest challenges related to the beginning of the COVID-19 pandemic. The interviews were carried out in March-June (five stages of the research) and in October (the 6 th stage of the research). A total of 115 in-depth individual interviews were conducted online with 20 respondents, in 6 stages. The results of the analysis showed that for all respondents the greatest challenges and the source of the greatest suffering were: a) limitation of direct contact with people; b) restrictions on movement and travel; c) necessary changes in active lifestyle; d) boredom and monotony; and e) uncertainty about the future.

Citation: Maison D, Jaworska D, Adamczyk D, Affeltowicz D (2021) The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study. PLoS ONE 16(10): e0258133. https://doi.org/10.1371/journal.pone.0258133

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: April 6, 2021; Accepted: September 18, 2021; Published: October 11, 2021

Copyright: © 2021 Maison et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files ( S1 Dataset ).

Funding: This work was supported by the Faculty of Psychology, University of Warsaw, Poland from the funds awarded by the Ministry of Science and Higher Education in the form of a subsidy for the maintenance and development of research potential in 2020 (501-D125-01-1250000). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The coronavirus disease (COVID-19), discovered in December 2019 in China, has reached the level of a pandemic and, till June 2021, it has affected more than 171 million people worldwide and caused more than 3.5 million deaths all over the world [ 1 ]. The COVID-19 pandemic as a major health crisis has caught the attention of many researchers, which has led to the creation of a broad quantitative picture of human behavior during the coronavirus outbreak [ 2 – 4 ]. What has been established so far is, among others, the psychological symptoms that can occur as a result of lockdown [ 2 ], and the most common coping strategies [ 5 ]. However, what we still miss is an in-depth understanding of the changes in the ways of coping with challenges over different stages of the pandemic. In the following study, we used a longitudinal qualitative method to investigate the challenges during the different waves of the coronavirus pandemic as well as the coping mechanisms accompanying them.

In Poland, the first patient was diagnosed with COVID-19 on the 4 th March 2020. Since then, the number of confirmed cases has grown to more than 2.8 million and the number of deaths to more than 73,000 (June 2021) [ 1 ]. From mid-March 2020, the Polish government, similarly to many other countries, began to introduce a number of restrictions to limit the spread of the virus. These restrictions had been changing from week to week, causing diverse reactions in people [ 6 ]. It needs to be noted that the reactions to such a dynamic situation cannot be covered by a single study. Therefore, in our study we used qualitative longitudinal research in order to monitor changes in people’s emotions, attitudes, and behavior. So far, few longitudinal studies have been carried out that investigated the various issues related to the COVID-19 pandemic; however, all of them were quantitative [ 7 – 10 ]. The qualitative approach (and especially the use of enabling and projective techniques) allows for an in-depth exploration of respondents’ reactions that goes beyond respondents’ declarations and captures what they are less aware of or even unconscious of. This study consisted of six stages of interviews that were conducted at key moments for the development of the pandemic situation in Poland. The first stage of the study was carried out at the moment of the most severe lockdown and the biggest restrictions (March 2020) and was focused on exploration how did people react to the new uncertain situation. The second stage of the study was conducted at the time when restrictions were extended and the obligation to cover the mouth and nose everywhere outside the household were introduced (middle of April 2020) and was focused at the way how did people deal with the lack of family gatherings over Easter. The third stage of the study was conducted at the moment of announcing the four stages of lifting the restrictions (April 2020) and was focused on people’s reaction to an emerging vision of getting back to normalcy. The fourth stage of the study was carried out, after the introduction of the second stage of lifting the restrictions: shopping malls, hotels, and cultural institutions were gradually being opened (May 2020). The fifth stage of the study was conducted after all four stages of restriction lifting were in place (June 2020). Only the obligation to cover the mouth and nose in public spaces, an order to maintain social distance, as well as the functioning of public places under a sanitary regime were still in effect. During those 5 stages coping strategies with the changes in restrictions were explored. The sixth and last stage of the study was a return to the respondents after a longer break, at the turn of October and November 2020, when the number of coronavirus cases in Poland began to increase rapidly and the media declared “the second wave of the pandemic”. It was the moment when the restrictions were gradually being reintroduced. A full description of the changes occurring in Poland at the time of the study can be found in S1 Table .

The following study is the first qualitative longitudinal study investigating how people cope with the challenges arising from the COVID-19 pandemic at its different stages. The study, although conducted in Poland, shows the universal psychological relations between the challenges posed by the pandemic (and, even more, the restrictions resulting from the pandemic, which were very similar across different countries, not only European) and the ways of dealing with them.

Literature review

The COVID-19 pandemic has led to a global health crisis with severe economic [ 11 ], social [ 3 ], and psychological consequences [ 4 ]. Despite the fact that there were multiple crises in recent years, such as natural disasters, economic crises, and even epidemics, the coronavirus pandemic is the first in 100 years to severely affect the entire world. The economic effects of the COVID-19 pandemic concern an impending global recession caused by the lockdown of non-essential industries and the disruption of production and supply chains [ 11 ]. Social consequences may be visible in many areas, such as the rise in family violence [ 3 ], the ineffectiveness of remote education, and increased food insecurity among impoverished families due to school closures [ 12 ]. According to some experts, the psychological consequences of COVID-19 are the ones that may persist for the longest and lead to a global mental health crisis [ 13 ]. The coronavirus outbreak is generating increased depressive symptoms, stress, anxiety, insomnia, denial, fear, and anger all over the world [ 2 , 14 ]. The economic, social, and psychological problems that people are currently facing are the consequences of novel challenges that have been posed by the pandemic.

The coronavirus outbreak is a novel, uncharted situation that has shaken the world and completely changed the everyday lives of many individuals. Due to the social distancing policy, many people have switched to remote work—in Poland, almost 75% of white-collar workers were fully or partially working from home from mid-March until the end of May 2020 [ 15 ]. School closures and remote learning imposed a new obligation on parents of supervising education, especially with younger children [ 16 ]. What is more, the government order of self-isolation forced people to spend almost all their time at home and limit or completely abandon human encounters. In addition, the deteriorating economic situation was the cause of financial hardship for many people. All these difficulties and challenges arose in the aura of a new, contagious disease with unexplored, long-lasting health effects and not fully known infectivity and lethality [ 17 ]. Dealing with the situation was not facilitated by the phenomenon of global misinformation, called by some experts as the “infodemic”, which may be defined as an overabundance of information that makes it difficult for people to find trustworthy sources and reliable guidance [ 18 ]. Studies have shown that people have multiple ways of reacting to a crisis: from radical and even violent practices, towards individual solutions and depression [ 19 ]. Not only the challenges arising from the COVID-19 pandemic but also the ways of reacting to it and coping with it are issues of paramount importance that are worth investigating.

The reactions to unusual crisis situations may be dependent on dispositional factors, such as trait anxiety or perceived control [ 20 , 21 ]. A study on reactions to Hurricane Hugo has shown that people with higher trait anxiety are more likely to develop posttraumatic symptoms following a natural disaster [ 20 ]. Moreover, lack of perceived control was shown to be positively related to the level of distress during an earthquake in Turkey [ 21 ]. According to some researchers, the COVID-19 crisis and natural disasters have much in common, as the emotions and behavior they cause are based on the same primal human emotion—fear [ 22 ]. Both pandemics and natural disasters disrupt people’s everyday lives and may have severe economic, social and psychological consequences [ 23 ]. However, despite many similarities to natural disasters, COVID-19 is a unique situation—only in 2020, the current pandemic has taken more lives than the world’s combined natural disasters in any of the past twenty years [ 24 ]. It needs to be noted that natural disasters may pose different challenges than health crises and for this reason, they may provoke disparate reactions [ 25 ]. Research on the reactions to former epidemics has shown that avoidance and safety behaviors, such as avoiding going out, visiting crowded places, and visiting hospitals, are widespread at such times [ 26 ]. When it comes to the ways of dealing with the current COVID-19 pandemic, a substantial part of the quantitative research on this issue focuses on coping mechanisms. Studies have shown that the most prevalent coping strategies are highly problem-focused [ 5 ]. Most people tend to listen to expert advice and behave calmly and appropriately in the face of the coronavirus outbreak [ 5 ]. Problem-focused coping is particularly characteristic of healthcare professionals. A study on Chinese nurses has shown that the closer the problem is to the person and the more fear it evokes, the more problem-focused coping strategy is used to deal with it [ 27 ]. On the other hand, a negative coping style that entails risky or aggressive behaviors, such as drug or alcohol use, is also used to deal with the challenges arising from the COVID-19 pandemic [ 28 ]. The factors that are correlated with negative coping include coronavirus anxiety, impairment, and suicidal ideation [ 28 ]. It is worth emphasizing that social support is a very important component of dealing with crises [ 29 ].

Scientists have attempted to systematize the reactions to difficult and unusual situations. One such concept is the “3 Cs” model created by Reich [ 30 ]. It accounts for the general rules of resilience in situations of stress caused by crises, such as natural disasters. The 3 Cs stand for: control (a belief that personal resources can be accessed to achieve valued goals), coherence (the human desire to make meaning of the world), and connectedness (the need for human contact and support) [ 30 ]. Polizzi and colleagues [ 22 ] reviewed this model from the perspective of the current COVID-19 pandemic. The authors claim that natural disasters and COVID-19 pandemic have much in common and therefore, the principles of resilience in natural disaster situations can also be used in the situation of the current pandemic [ 22 ]. They propose a set of coping behaviors that could be useful in times of the coronavirus outbreak, which include control (e.g., planning activities for each day, getting adequate sleep, limiting exposure to the news, and helping others), coherence (e.g., mindfulness and developing a coherent narrative on the event), and connectedness (e.g., establishing new relationships and caring for existing social bonds) [ 22 ].

Current study

The issue of the challenges arising from the current COVID-19 pandemic and the ways of coping with them is complex and many feelings accompanying these experiences may be unconscious and difficult to verbalize. Therefore, in order to explore and understand it deeply, qualitative methodology was applied. Although there were few qualitative studies on the reaction to the pandemic [e.g., 31 – 33 ], they did not capture the perception of the challenges and their changes that arise as the pandemic develops. Since the situation with the COVID-19 pandemic is very dynamic, the reactions to the various restrictions, orders or bans are evolving. Therefore, it was decided to conduct a qualitative longitudinal study with multiple interviews with the same respondents [ 34 ].

The study investigates the challenges arising from the current pandemic and the way people deal with them. The main aim of the project was to capture people’s reactions to the unusual and unexpected situation of the COVID-19 pandemic. Therefore, the project was largely exploratory in nature. Interviews with the participants at different stages of the epidemic allowed us to see a wide spectrum of problems and ways of dealing with them. The conducted study had three main research questions:

• What are the biggest challenges connected to the COVID-19 pandemic and the resulting restrictions?
• How are people dealing with the pandemic challenges?
• What are the ways of coping with the restrictions resulting from a pandemic change as it continues and develops (perspective of first 6 months)?

The study was approved by the institutional review board of the Faculty of Psychology University of Warsaw, Poland. All participants were provided written and oral information about the study, which included that participation was voluntary, that it was possible to withdraw without any consequences at any time, and the precautions that would be taken to protect data confidentiality. Informed consent was obtained from all participants. To ensure confidentiality, quotes are presented only with gender, age, and family status.

The study was based on qualitative methodology: individual in-depth interviews, s which are the appropriate to approach a new and unknown and multithreaded topic which, at the beginning of 2020, was the COVID-19 pandemic. Due to the need to observe respondents’ reactions to the dynamically changing situation of the COVID-19 pandemic, longitudinal study was used where the moderator met on-line with the same respondent several times, at specific time intervals. A longitudinal study was used to capture the changes in opinions, emotions, and behaviors of the respondents resulting from the changes in the external circumstances (qualitative in-depth interview tracking–[ 34 ]).

The study took place from the end of March to October 2020. Due to the epidemiological situation in the country interviews took place online, using the Google Meets online video platform. The audio was recorded and then transcribed. Before taking part in the project, the respondents were informed about the purpose of the study, its course, and the fact that participation in the project is voluntary, and that they will be able to withdraw from participation at any time. The respondents were not paid for taking part in the project.

Participants.

In total, 115 interviews were conducted with 20 participants (6 interviews with the majority of respondents). Two participants (number 11 and 19, S2 Table ) dropped out of the last two interviews, and one (number 6) dropped out of the last interview. The study was based on a purposive sample and the respondents differed in gender, age, education, family status, and work situation (see S2 Table ). In addition to demographic criteria intended to ensure that the sample was as diverse as possible, an additional criterion was to have a permanent Internet connection and a computer capable of online video interviewing. Study participants were recruited using the snowball method. They were distant acquaintances of acquaintances of individuals involved in the study. None of the moderators knew their interviewees personally.

A total of 10 men and 10 women participated in the study; their age range was: 25–55; the majority had higher education (17 respondents), they were people with different professions and work status, and different family status (singles, couples without children, and families with children). Such diversity of respondents allowed us to obtain information from different life perspectives. A full description of characteristics of study participants can be found in S2 Table .

Each interview took 2 hours on average, which gives around 240 hours of interviews. Subsequent interviews with the same respondents conducted at different intervals resulted from the dynamics of the development of the pandemic and the restrictions introduced in Poland by the government.

The interviews scenario took a semi-structured form. This allowed interviewers freely modify the questions and topics depending on the dynamics of the conversation and adapt the subject matter of the interviews not only to the research purposes but also to the needs of a given respondent. The interview guides were modified from week to week, taking into account the development of the epidemiological situation, while at the same time maintaining certain constant parts that were repeated in each interview. The main parts of the interview topic guide consisted of: (a) experiences from the time of previous interviews: thoughts, feeling, fears, and hopes; (b) everyday life—organization of the day, work, free time, shopping, and eating, etc.; (c) changes—what had changed in the life of the respondent from the time of the last interview; (d) ways of coping with the situation; and (e) media—reception of information appearing in the media. Additionally, in each interview there were specific parts, such as the reactions to the beginning of the pandemic in the first interview or the reaction to the specific restrictions that were introduced.

The interviews were conducted by 5 female interviewers with experience in moderating qualitative interviews, all with a psychological background. After each series of interviews, all the members of the research teams took part in debriefing sessions, which consisted of discussing the information obtained from each respondent, exchanging general conclusions, deciding about the topics for the following interview stage, and adjusting them to the pandemic situation in the country.

Data analysis.

All the interviews were transcribed in Polish by the moderators and then double-checked (each moderator transcribed the interviews of another moderator, and then the interviewer checked the accuracy of the transcription). The whole process of analysis was conducted on the material in Polish (the native language of the authors of the study and respondents). The final page count of the transcript is approximately 1800 pages of text. The results presented below are only a portion of the total data collected during the interviews. While there are about 250 pages of the transcription directly related to the topic of the article, due to the fact that the interview was partly free-form, some themes merge with others and it is not possible to determine the exact number of pages devoted exclusively to analysis related to the topic of the article. Full dataset can be found in S1 Dataset .

Data was then processed into thematic analysis, which is defined as a method of developing qualitative data consisting of the identification, analysis, and description of the thematic areas [ 35 ]. In this type of analysis, a thematic unit is treated as an element related to the research problem that includes an important aspect of data. An important advantage of thematic analysis is its flexibility, which allows for the adoption of the most appropriate research strategy to the phenomenon under analysis. An inductive approach was used to avoid conceptual tunnel vision. Extracting themes from the raw data using an inductive approach precludes the researcher from imposing a predetermined outcome.

As a first step, each moderator reviewed the transcripts of the interviews they had conducted. Each transcript was thematically coded individually from this point during the second and the third reading. In the next step, one of the researchers reviewed the codes extracted by the other members of the research team. Then she made initial interpretations by generating themes that captured the essence of the previously identified codes. The researcher created a list of common themes present in all of the interviews. In the next step, the extracted themes were discussed again with all the moderators conducting the coding in order to achieve consistency. This collaborative process was repeated several times during the analysis. Here, further superordinate (challenges of COVID-19 pandemic) and subordinate (ways of dealing with challenges) themes were created, often by collapsing others together, and each theme listed under a superordinate and subordinate category was checked to ensure they were accurately represented. Through this process of repeated analysis and discussion of emerging themes, it was possible to agree on the final themes that are described below.

Main challenges of the COVID-19 pandemic.

Challenge 1 –limitation of direct contact with people . The first major challenge of the pandemic was that direct contact with other people was significantly reduced. The lockdown forced many people to work from home and limit contact not only with friends but also with close family (parents, children, and siblings). Limiting contact with other people was a big challenge for most of our respondents, especially those who were living alone and for those who previously led an active social life. Depending on their earlier lifestyle profile, for some, the bigger problem was the limitation of contact with the family, for others with friends, and for still others with co-workers.

I think that because I can’t meet up with anyone and that I’m not in a relationship , I miss having sex , and I think it will become even more difficult because it will be increasingly hard to meet anyone . (5 . 3_ M_39_single) . The number In the brackets at the end of the quotes marks the respondent’s number (according to Table 1 ) and the stage of the interview (after the dash), further is information about gender (F/M), age of the respondent and family status. Linguistic errors in the quotes reflect the spoken language of the respondents.

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https://doi.org/10.1371/journal.pone.0258133.t001

Changes over time . Over the course of the 6 months of the study, an evolution in the attitudes to the restriction of face-to-face contact could be seen: from full acceptance, to later questioning its rationale. Initially (March and April), almost all the respondents understood the reasons for the isolation and were compliant. At the beginning, people were afraid of the unknown COVID-19. They were concerned that the tragic situation from Italy, which was intensively covered in the media, could repeat itself in Poland (stage 1–2 of the study). However, with time, the isolation started to bother them more and more, and they started to look for solutions to bypass the isolation guidelines (stage 3–4), both real (simply meeting each other) and mental (treating isolation only as a guideline and not as an order, perceiving the family as being less threatening than acquaintances or strangers in a store). The turning point was the long May weekend that, due to two public holidays (1 st and 3 rd May), has for many years been used as an opportunity to go away with family or friends. Many people broke their voluntary isolation during that time encouraged by information about the coming loosening of restrictions.

During the summer (stage 5 of the survey), practically no one was fully compliant with the isolation recommendations anymore. At that time, a growing familiarity could be observed with COVID-19 and an increasing tendency to talk about it as “one of many diseases”, and to convince oneself that one is not at risk and that COVID-19 is no more threatening than other viruses. Only a small group of people consciously failed to comply with the restrictions of contact with others from the very beginning of the pandemic. This behavior was mostly observed among people who were generally less anxious and less afraid of COVID-19.

I’ve had enough. I’ve had it with sitting at home. Okay, there’s some kind of virus, it’s as though it’s out there somewhere; it’s like I know 2 people who were infected but they’re still alive, nothing bad has happened to anyone. It’s just a tiny portion of people who are dying. And is it really such a tragedy that we have to be locked up at home? Surely there’s an alternative agenda there? (17.4_F_35_Adult and child)

Ways of dealing . In the initial phase, when almost everyone accepted this restriction and submitted to it, the use of communication platforms for social meetings increased (see Ways of dealing with challenges in Table 1 ) . Meetings on communication platforms were seen as an equivalent of the previous face-to-face contact and were often even accompanied by eating or drinking alcohol together. However, over time (at around stage 4–5 of the study) people began to feel that such contact was an insufficient substitute for face-to-face meetings and interest in online meetings began to wane. During this time, however, an interesting phenomenon could be seen, namely, that for many people the family was seen as a safer environment than friends, and definitely safer than strangers. The belief was that family members would be honest about being sick, while strangers not necessarily, and—on an unconscious level—the feeling was that the “family is safe”, and the “family can’t hurt them”.

When it became clear that online communication is an insufficient substitute for face-to-face contacts, people started to meet up in real life. However, a change in many behaviors associated with meeting people is clearly visible, e.g.: refraining from shaking hands, refraining from cheek kissing to greet one another, and keeping a distance during a conversation.

I can’t really say that I could ‘feel’ Good Friday or Holy Saturday. On Sunday, we had breakfast together with my husband’s family and his sister. We were in three different places but we connected over Skype. Later, at noon, we had some coffee with my parents, also over Skype. It’s obvious though that this doesn’t replace face-to-face contact but it’s always some form of conversation. (9.3_F_25_Couple, no children)

Challenge 2 –restrictions on movement and travel . In contrast to the restrictions on contact with other people, the restrictions on movement and the closing of borders were perceived more negatively and posed bigger challenges for some people (especially those who used to do a lot of travelling). In this case, it was less clear why these regulations were introduced (especially travel restrictions within the country). Moreover, travel restrictions, particularly in the case of international travels, were associated with a limitation of civil liberties. The limitation (or complete ban) on travelling abroad in the Polish situation evoked additional connotations with the communist times, that is, with the fact that there was no freedom of movement for Polish citizens (associations with totalitarianism and dictatorship). Interestingly, the lack of acceptance of this restriction was also manifested by people who did not travel much. Thus, it was not just a question of restricting travelling abroad but more of restricting the potential opportunity (“even if I’m not planning on going anywhere, I know I still can”).

Limitations on travelling around the country were particularly negatively felt by families with children, where parents believe that regular exercise and outings are necessary for the proper development of their children. For parents, it was problematic to accept the prohibition of leaving the house and going to the playground (which remained closed until mid-May). Being outdoors was perceived as important for maintaining immunity (exercise as part of a healthy lifestyle), therefore, people could not understand the reason underlying this restriction and, as a consequence, often did not accept it.

I was really bothered by the very awareness that I can’t just jump in my car or get on a plane whenever I want and go wherever I want. It’s not something that I have to do on a daily basis but freedom of movement and travelling are very important for me. (14.2_M_55_Two adults and children)

Changes over time . The travel and movement limitations, although objectively less severe for most people, aroused much greater anger than the restrictions on social contact. This was probably due to a greater sense of misunderstanding as to why these rules were being introduced in the first place. Moreover, they were often communicated inconsistently and chaotically (e.g., a ban on entering forests was introduced while, at the same time, shopping malls remained open and masses were allowed to attend church services). This anger grew over time—from interview to interview, the respondents’ irritation and lack of acceptance of this was evident (culminating in the 3 rd -4 th stage of the study). The limitation of mobility was also often associated with negative consequences for both health and the economy. Many people are convinced that being in the open air (especially accompanied by physical activity) strengthens immunity, therefore, limiting such activity may have negative health consequences. Some respondents pointed out that restricting travelling, the use of hotels and restaurants, especially during the holiday season, will have serious consequences for the existence of the tourism industry.

I can’t say I completely agree with these limitations because it’s treating everything selectively. It’s like the shopping mall is closed, I can’t buy any shoes but I can go to a home improvement store and buy some wallpaper for myself. So I don’t see the difference between encountering people in a home improvement store and a shopping mall. (18.2_F_48_Two adults and children)

Ways of dealing . Since the restriction of movement and travel was more often associated with pleasure-related behaviors than with activities necessary for living, the compensations for these restrictions were usually also from the area of hedonistic behaviors. In the statements of our respondents, terms such as “indulging” or “rewarding oneself” appeared, and behaviors such as throwing small parties at home, buying better alcohol, sweets, and new clothes were observed. There were also increased shopping behaviors related to hobbies (sometimes hobbies that could not be pursued at the given time)–a kind of “post-pandemic” shopping spree (e.g., a new bike or new skis).

Again, the reaction to this restriction also depended on the level of fear of the COVID-19 disease. People who were more afraid of being infected accepted these restrictions more easily as it gave them the feeling that they were doing something constructive to protect themselves from the infection. Conversely, people with less fears and concerns were more likely to rebel and break these bans and guidelines.

Another way of dealing with this challenge was making plans for interesting travel destinations for the post-pandemic period. This was especially salient in respondents with an active lifestyle in the past and especially visible during the 5 th stage of the study.

Today was the first day when I went to the store (due to being in quarantine after returning from abroad). I spent loads of money but I normally would have never spent so much on myself. I bought sweets and confectionery for Easter time, some Easter chocolates, too. I thought I’d do some more baking so I also bought some ingredients to do this. (1.2_ F_25_single)

Challenge 3 –necessary change in active lifestyle . Many of the limitations related to COVID-19 were a challenge for people with an active lifestyle who would regularly go to the cinema, theater, and gym, use restaurants, and do a lot of travelling. For those people, the time of the COVID constraints has brought about huge changes in their lifestyle. Most of their activities were drastically restricted overnight and they suddenly became domesticated by force, especially when it was additionally accompanied by a transition to remote work.

Compulsory spending time at home also had serious consequences for people with school-aged children who had to confront themselves with the distance learning situation of their children. The second challenge for families with children was also finding (or helping find) activities for their children to do in their free time without leaving the house.

I would love to go to a restaurant somewhere. We order food from the restaurant at least once a week, but I’d love to go to the restaurant. Spending time there is a different way of functioning. It is enjoyable and that is what I miss. I would also go to the cinema, to the theater. (13.3_M_46_Two adults and child.)

Changes over time . The nuisance of restrictions connected to an active lifestyle depended on the level of restrictions in place at a given time and the extent to which a given activity could be replaced by an alternative. Moreover, the response to these restrictions depended more on the individual differences in lifestyle rather than on the stage of the interview (except for the very beginning, when the changes in lifestyle and everyday activities were very sudden).

I miss that these restaurants are not open . And it’s not even that I would like to eat something specific . It is in all of this that I miss such freedom the most . It bothers me that I have no freedom . And I am able to get used to it , I can cook at home , I can order from home . But I just wish I had a choice . (2 . 6_F_27_single ).

Ways of dealing . In the initial phase of the pandemic (March-April—stage 1–3 of the study), when most people were afraid of the coronavirus, the acceptance of the restrictions was high. At the same time, efforts were made to find activities that could replace existing ones. Going to the gym was replaced by online exercise, and going to the cinema or theater by intensive use of streaming platforms. In the subsequent stages of the study, however, the respondents’ fatigue with these “substitutes” was noticeable. It was then that more irritation and greater non-acceptance of certain restrictions began to appear. On the other hand, the changes or restrictions introduced during the later stages of the pandemic were less sudden than the initial ones, so they were often easier to get used to.

I bought a small bike and even before that we ordered some resistance bands to work out at home, which replace certain gym equipment and devices. […] I’m considering learning a language. From the other online things, my girlfriend is having yoga classes, for instance. (7.2_M_28_Couple, no children)

Challenge 4 –boredom , monotony . As has already been shown, for many people, the beginning of the pandemic was a huge change in lifestyle, an absence of activities, and a resulting slowdown. It was sometimes associated with a feeling of weariness, monotony, and even of boredom, especially for people who worked remotely, whose days began to be similar to each other and whose working time merged with free time, weekdays with the weekends, and free time could not be filled with previous activities.

In some way, boredom. I can’t concentrate on what I’m reading. I’m trying to motivate myself to do such things as learning a language because I have so much time on my hands, or to do exercises. I don’t have this balance that I’m actually doing something for myself, like reading, working out, but also that I’m meeting up with friends. This balance has gone, so I’ve started to get bored with many things. Yesterday I felt that I was bored and something should start happening. (…) After some time, this lack of events and meetings leads to such immense boredom. (1.5_F_25_single)

Changes over time . The feeling of monotony and boredom was especially visible in stage 1 and 2 of the study when the lockdown was most restrictive and people were knocked out of their daily routines. As the pandemic continued, boredom was often replaced by irritation in some, and by stagnation in others (visible in stages 3 and 4 of the study) while, at the same time, enthusiasm for taking up new activities was waning. As most people were realizing that the pandemic was not going to end any time soon, a gradual adaptation to the new lifestyle (slower and less active) and the special pandemic demands (especially seen in stage 5 and 6 of the study) could be observed.

But I see that people around me , in fact , both family and friends , are slowly beginning to prepare themselves for more frequent stays at home . So actually more remote work , maybe everything will not be closed and we will not be locked in four walls , but this tendency towards isolation or self-isolation , such a deliberate one , appears . I guess we are used to the fact that it has to be this way . (15 . 6_M_43_Two adults and child) .

Ways of dealing . The answer to the monotony of everyday life and to finding different ways of separating work from free time was to stick to certain rituals, such as “getting dressed for work”, even when work was only by a computer at home or, if possible, setting a fixed meal time when the whole family would gather together. For some, the time of the beginning of the pandemic was treated as an extra vacation. This was especially true of people who could not carry out their work during the time of the most severe restrictions (e.g., hairdressers and doctors). For them, provided that they believed that everything would return to normal and that they would soon go back to work, a “vacation mode” was activated wherein they would sleep longer, watch a lot of movies, read books, and generally do pleasant things for which they previously had no time and which they could now enjoy without feeling guilty. Another way of dealing with the monotony and transition to a slower lifestyle was taking up various activities for which there was no time before, such as baking bread at home and cooking fancy dishes.

I generally do have a set schedule. I begin work at eight. Well, and what’s changed is that I can get up last minute, switch the computer on and be practically making my breakfast and coffee during this time. I do some work and then print out some materials for my younger daughter. You know, I have work till four, I keep on going up to the computer and checking my emails. (19.1_F_39_Two adults and children)

Challenge 5 –uncertainty about the future . Despite the difficulties arising from the circumstances and limitations described above, it seems that psychologically, the greatest challenge during a pandemic is the uncertainty of what will happen next. There was a lot of contradictory information in the media that caused a sense of confusion and heightened the feeling of anxiety.

I’m less bothered about the changes that were put in place and more about this concern about what will happen in the future. Right now, it’s like there’s these mood swings. […] Based on what’s going on, this will somehow affect every one of us. And that’s what I’m afraid of. The fact that someone will not survive and I have no way of knowing who this could be—whether it will be me or anyone else, or my dad, if somehow the coronavirus will sneak its way into our home. I simply don’t know. I’m simply afraid of this. (10.1_F_55_Couple, no children)

Changes over time . In the first phase of the pandemic (interviews 1–3), most people felt a strong sense of not being in control of the situation and of their own lives. Not only did the consequences of the pandemic include a change in lifestyle but also, very often, the suspension of plans altogether. In addition, many people felt a strong fear of the future, about what would happen, and even a sense of threat to their own or their loved ones’ lives. Gradually (interview 4), alongside anxiety, anger began to emerge about not knowing what would happen next. At the beginning of the summer (stage 5 of the study), most people had a hope of the pandemic soon ending. It was a period of easing restrictions and of opening up the economy. Life was starting to look more and more like it did before the pandemic, fleetingly giving an illusion that the end of the pandemic was “in sight” and the vision of a return to normal life. Unfortunately, autumn showed that more waves of the pandemic were approaching. In the interviews of the 6 th stage of the study, we could see more and more confusion and uncertainty, a loss of hope, and often a manifestation of disagreement with the restrictions that were introduced.

This is making me sad and angry. More angry, in fact. […] I don’t know what I should do. Up until now, there was nothing like this. Up until now, I was pretty certain of what I was doing in all the decisions I was making. (14.4_M_55_Two adults and children)

Ways of dealing . People reacted differently to the described feeling of insecurity. In order to reduce the emerging fears, some people searched (sometimes even compulsively) for any information that could help them “take control” of the situation. These people searched various sources, for example, information on the number of infected persons and the number of deaths. This knowledge gave them the illusion of control and helped them to somewhat reduce the anxiety evoked by the pandemic. The behavior of this group was often accompanied by very strict adherence to all guidelines and restrictions (e.g., frequent hand sanitization, wearing a face mask, and avoiding contact with others). This behavior increased the sense of control over the situation in these people.

A completely opposite strategy to reducing the feeling of uncertainty which we also observed in some respondents was cutting off information in the media about the scale of the disease and the resulting restrictions. These people, unable to keep up with the changing information and often inconsistent messages, in order to maintain cognitive coherence tried to cut off the media as much as possible, assuming that even if something really significant had happened, they would still find out.

I want to keep up to date with the current affairs. Even if it is an hour a day. How is the pandemic situation developing—is it increasing or decreasing. There’s a bit of propaganda there because I know that when they’re saying that they have the situation under control, they can’t control it anyway. Anyhow, it still has a somewhat calming effect that it’s dying down over here and that things aren’t that bad. And, apart from this, I listen to the news concerning restrictions, what we can and can’t do. (3.1_F_54_single)

Discussion and conclusions

The results of our study showed that the five greatest challenges resulting from the COVID-19 pandemic are: limitations of direct contact with people, restrictions on movement and travel, change in active lifestyle, boredom and monotony, and finally uncertainty about the future. As we can see the spectrum of problems resulting from the pandemic is very wide and some of them have an impact on everyday functioning and lifestyle, some other influence psychological functioning and well-being. Moreover, different people deal with these problems differently and different changes in everyday life are challenging for them. The first challenge of the pandemic COVID-19 problem is the consequence of the limitation of direct contact with others. This regulation has very strong psychological consequences in the sense of loneliness and lack of closeness. Initially, people tried to deal with this limitation through the use of internet communicators. It turned out, however, that this form of contact for the majority of people was definitely insufficient and feelings of deprivation quickly increased. As much data from psychological literature shows, contact with others can have great psychological healing properties [e.g., 29 ]. The need for closeness is a natural need in times of crisis and catastrophes [ 30 ]. Unfortunately, during the COVID-19 pandemic, the ability to meet this need was severely limited by regulations. This led to many people having serious problems with maintaining a good psychological condition.

Another troubling limitation found in our study were the restrictions on movement and travel, and the associated restrictions of most activities, which caused a huge change in lifestyle for many people. As shown in previous studies, travel and diverse leisure activities are important predictors of greater well-being [ 36 ]. Moreover, COVID-19 pandemic movement restrictions may be perceived by some people as a threat to human rights [ 37 ], which can contribute to people’s reluctance to accept lockdown rules.

The problem with accepting these restrictions was also related to the lack of understanding of the reasons behind them. Just as the limitation in contact with other people seemed understandable, the limitations related to physical activity and mobility were less so. Because of these limitations many people lost a sense of understanding of the rules and restrictions being imposed. Inconsistent communication in the media—called by some researchers the ‘infodemic’ [ 18 ], as well as discordant recommendations in different countries, causing an increasing sense of confusion in people.

Another huge challenge posed by the current pandemic is the feeling of uncertainty about the future. This feeling is caused by constant changes in the rules concerning daily functioning during the pandemic and what is prohibited and what is allowed. People lose their sense of being in control of the situation. From the psychological point of view, a long-lasting experience of lack of control can cause so-called learned helplessness, a permanent feeling of having no influence over the situation and no possibility of changing it [ 38 ], which can even result in depression and lower mental and physical wellbeing [ 39 ]. Control over live and the feeling that people have an influence on what happens in their lives is one of the basic rules of crisis situation resilience [ 30 ]. Unfortunately, also in this area, people have huge deficits caused by the pandemic. The obtained results are coherent with previous studies regarding the strategies harnessed to cope with the pandemic [e.g., 5 , 10 , 28 , 33 ]. For example, some studies showed that seeking social support is one of the most common strategies used to deal with the coronavirus pandemic [ 33 , 40 ]. Other ways to deal with this situation include distraction, active coping, and a positive appraisal of the situation [ 41 ]. Furthermore, research has shown that simple coping behaviors such as a healthy diet, not reading too much COVID-19 news, following a daily routine, and spending time outdoors may be protective factors against anxiety and depressive symptoms in times of the coronavirus pandemic [ 41 ].

This study showed that the acceptance of various limitations, and especially the feeling of discomfort associated with them, depended on the person’s earlier lifestyle. The more active and socializing a person was, the more restrictions were burdensome for him/her. The second factor, more of a psychological nature, was the fear of developing COVID-19. In this case, people who were more afraid of getting sick were more likely to submit to the imposed restrictions that, paradoxically, did not reduce their anxiety, and sometimes even heightened it.

Limitations of the study.

While the study shows interesting results, it also has some limitations. The purpose of the study was primarily to capture the first response to problems resulting from a pandemic, and as such its design is not ideal. First, the study participants are not diverse as much as would be desirable. They are mostly college-educated and relatively well off, which may influence how they perceive the pandemic situation. Furthermore, the recruitment was done by searching among the further acquaintances of the people involved in the study, so there is a risk that all the people interviewed come from a similar background. It would be necessary to conduct a study that also describes the reaction of people who are already in a more difficult life situation before the pandemic starts.

Moreover, it would also be worthwhile to pay attention to the interviewers themselves. All of the moderators were female, and although gender effects on the quality of the interviews and differences between the establishment of relationships between women and men were not observed during the debriefing process, the topic of gender effects on the results of qualitative research is frequently addressed in the literature [ 42 , 43 ]. Although the researchers approached the process with reflexivity and self-criticism at all stages, it would have seemed important to involve male moderators in the study to capture any differences in relationship dynamics.

Practical implications.

The study presented has many practical implications. Decision-makers in the state can analyze the COVID-19 pandemic crisis in a way that avoids a critical situation involving other infectious diseases in the future. The results of our study showing the most disruptive effects of the pandemic on people can serve as a basis for developing strategies to deal with the effects of the crisis so that it does not translate into a deterioration of the public’s mental health in the future.

The results of our study can also provide guidance on how to communicate information about restrictions in the future so that they are accepted and respected (for example by giving rational explanations of the reasons for introducing particular restrictions). In addition, the results of our study can also be a source of guidance on how to deal with the limitations that may arise in a recurrent COVID-19 pandemic, as well as other emergencies that could come.

The analysis of the results showed that the COVID-19 pandemic, and especially the lockdown periods, are a particular challenge for many people due to reduced social contact. On the other hand, it is social contacts that are at the same time a way of a smoother transition of crises. This knowledge should prompt decision-makers to devise ways to ensure pandemic safety without drastically limiting social contacts and to create solutions that give people a sense of control (instead of depriving it of). Providing such solutions can reduce the psychological problems associated with a pandemic and help people to cope better with it.

Conclusions

As more and more is said about the fact that the COVID-19 pandemic may not end soon and that we are likely to face more waves of this disease and related lockdowns, it is very important to understand how the different restrictions are perceived, what difficulties they cause and what are the biggest challenges resulting from them. For example, an important element of accepting the restrictions is understanding their sources, i.e., what they result from, what they are supposed to prevent, and what consequences they have for the fight against the pandemic. Moreover, we observed that the more incomprehensible the order was, the more it provoked to break it. This means that not only medical treatment is extremely important in an effective fight against a pandemic, but also appropriate communication.

The results of our study showed also that certain restrictions cause emotional deficits (e.g., loneliness, loss of sense of control) and, consequently, may cause serious problems with psychological functioning. From this perspective, it seems extremely important to understand which restrictions are causing emotional problems and how they can be dealt with in order to reduce the psychological discomfort associated with them.

Supporting information

S1 table. a full description of the changes occurring in poland at the time of the study..

https://doi.org/10.1371/journal.pone.0258133.s001

S2 Table. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0258133.s002

S1 Dataset. Transcriptions from the interviews.

https://doi.org/10.1371/journal.pone.0258133.s003

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• Volume 10, Issue 12
• Impact of the COVID-19 pandemic on mental health and well-being of communities: an exploratory qualitative study protocol
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• http://orcid.org/0000-0003-0180-0213 Anam Shahil Feroz 1 , 2 ,
• Naureen Akber Ali 3 ,
• Noshaba Akber Ali 1 ,
• Ridah Feroz 4 ,
• Salima Nazim Meghani 1 ,
• Sarah Saleem 1
• 1 Community Health Sciences , Aga Khan University , Karachi , Pakistan
• 2 Institute of Health Policy, Management and Evaluation , University of Toronto , Toronto , Ontario , Canada
• 3 School of Nursing and Midwifery , Aga Khan University , Karachi , Pakistan
• 4 Aga Khan University Institute for Educational Development , Karachi , Pakistan
• Correspondence to Ms Anam Shahil Feroz; anam.sahyl{at}gmail.com

Introduction The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. In addition, with the widespread use of social media, rumours, myths and inaccurate information about the virus are spreading rapidly, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes of community members towards COVID-19 and its impact on their daily lives and mental well-being.

Methods and analysis This formative research will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews with community members. The study will be conducted in the Karimabad Federal B Area and in the Garden (East and West) community settings in Karachi, Pakistan. The community members of these areas have been selected purposively for the interview. Study data will be analysed thematically using NVivo V.12 Plus software.

Ethics and dissemination Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The results of the study will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

• mental health
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-041641

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Strengths and limitations of this study

The mental health impact of the COVID-19 pandemic is likely to last much longer than the physical health impact, and this study is positioned well to explore the perceptions and attitudes of community members towards the pandemic and its impact on their daily lives and mental well-being.

This study will guide the development of context-specific innovative mental health programmes to support communities in the future.

One limitation is that to minimise the risk of infection all study respondents will be interviewed online over Zoom and hence the authors will not have the opportunity to build rapport with the respondents or obtain non-verbal cues during interviews.

The COVID-19 pandemic has affected almost 180 countries since it was first detected in Wuhan, China in December 2019. 1 2 The COVID-19 outbreak has been declared a public health emergency of international concern by the WHO. 3 The WHO estimates the global mortality to be about 3.4% 4 ; however, death rates vary between countries and across age groups. 5 In Pakistan, a total of 10 880 cases and 228 deaths due to COVID-19 infection have been reported to date. 6

The worldwide COVID-19 pandemic has not only incurred massive challenges to the global supply chains and healthcare systems but also has a detrimental effect on the overall health of individuals. 7 The pandemic has led to lockdowns and has created destructive impact on the societies at large. Most company employees, including daily wage workers, have been prohibited from going to their workplaces or have been asked to work from home, which has caused job-related insecurities and financial crises in the communities. 8 Educational institutions and training centres have also been closed, which resulted in children losing their routine of going to schools, studying and socialising with their peers. Delay in examinations is likewise a huge stressor for students. 8 Alongside this, parents have been struggling with creating a structured milieu for their children. 9 COVID-19 has hindered the normal routine life of every individual, be it children, teenagers, adults or the elderly. The crisis is engendering burden throughout populations and communities, particularly in developing countries such as Pakistan which face major challenges due to fragile healthcare systems and poor economic structures. 10

The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. 8 Further, the highly contagious nature of COVID-19 has also escalated confusion, fear and panic among community residents. Moreover, social distancing is often an unpleasant experience for community members and for patients as it adds to mental suffering, particularly in the local setting where get-togethers with friends and families are a major source of entertainment. 9 Recent studies also showed that individuals who are following social distancing rules experience loneliness, causing a substantial level of distress in the form of anxiety, stress, anger, misperception and post-traumatic stress symptoms. 8 11 Separation from family members, loss of autonomy, insecurity over disease status, inadequate supplies, inadequate information, financial loss, frustration, stigma and boredom are all major stressors that can create drastic impact on an individual’s life. 11 Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. 12 With the widespread use of social media, 13 rumours, myths and inaccurate information about COVID-19 are also spreading rapidly, not only among adults but are also carried on to children, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. 9 The psychological symptoms associated with COVID-19 at the community level are also manifested as anxiety-driven panic buying, resulting in exhaustion of resources from the market. 14 Some level of panic also dwells in the community due to the unavailability of essential protective equipment, particularly masks and sanitisers. 15 Similarly, mental health issues, including depression, anxiety, panic attacks, psychotic symptoms and even suicide, were reported during the early severe acute respiratory syndrome outbreak. 16 17 COVID-19 is likely posing a similar risk throughout the world. 12

The fear of transmitting the disease or a family member falling ill is a probable mental function of human nature, but at some point the psychological fear of the disease generates more anxiety than the disease itself. Therefore, mental health problems are likely to increase among community residents during an epidemic situation. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes towards COVID-19 among community residents and the impact of these perceptions and attitude on their daily lives and mental well-being.

Methods and analysis

Study design.

This study will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews (IDIs) with community members. The IDIs aim to explore perceptions of community members towards COVID-19 and its impact on their mental well-being.

Study setting and study participants

The study will be conducted in two communities in Karachi City: Karimabad Federal B Area Block 3 Gulberg Town, and Garden East and Garden West. Karimabad is a neighbourhood in the Karachi Central District of Karachi, Pakistan, situated in the south of Gulberg Town bordering Liaquatabad, Gharibabad and Federal B Area. The population of this neighbourhood is predominantly Ismailis. People living here belong mostly to the middle class to the lower middle class. It is also known for its wholesale market of sports goods and stationery. Garden is an upmarket neighbourhood in the Karachi South District of Karachi, Pakistan, subdivided into two neighbourhoods: Garden East and Garden West. It is the residential area around the Karachi Zoological Gardens; hence, it is popularly known as the ‘Garden’ area. The population of Garden used to be primarily Ismailis and Goan Catholics but has seen an increasing number of Memons, Pashtuns and Baloch. These areas have been selected purposively because the few members of these communities are already known to one of the coinvestigators. The coinvestigator will serve as a gatekeeper for providing entrance to the community for the purpose of this study. Adult community members of different ages and both genders will be interviewed from both sites, as mentioned in table 1 . Interview participants will be selected following the eligibility criteria.

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Study participants for indepth interviews

IDIs with community members

We will conduct IDIs with community members to explore the perceptions and attitudes of community members towards COVID-19 and its effects on their daily lives and mental well-being. IDI participants will be identified via the community WhatsApp group, and will be invited for an interview via a WhatsApp message or email. Consent will be taken over email or WhatsApp before the interview begins, where they will agree that the interview can be audio-recorded and that written notes can be taken. The interviews will be conducted either in Urdu or in English language, and each interview will last around 40–50 min. Study participants will be assured that their information will remain confidential and that no identifying features will be mentioned on the transcript. The major themes will include a general discussion about participants’ knowledge and perceptions about the COVID-19 pandemic, perceptions on safety measures, and perceived challenges in the current situation and its impact on their mental well-being. We anticipate that 24–30 interviews will be conducted, but we will cease interviews once data saturation has been achieved. Data saturation is the point when no new themes emerge from the additional interviews. Data collection will occur concurrently with data analysis to determine data saturation point. The audio recordings will be transcribed by a transcriptionist within 24 hours of the interviews.

An interview guide for IDIs is shown in online supplemental annex 1 .

Supplemental material

Eligibility criteria.

The following are the criteria for inclusion and exclusion of study participants:

Inclusion criteria

Residents of Garden (East and West) and Karimabad Federal B Area of Karachi who have not contracted the disease.

Exclusion criteria

Those who refuse to participate in the study.

Those who have experienced COVID-19 and are undergoing treatment.

Those who are suspected for COVID-19 and have been isolated/quarantined.

Family members of COVID-19-positive cases.

Data collection procedure

A semistructured interview guide has been developed for community members. The initial questions on the guide will help to explore participants’ perceptions and attitudes towards COVID-19. Additional questions on the guide will assess the impact of these perceptions and attitude on the daily lives and mental health and well-being of community residents. All semistructured interviews will be conducted online via Zoom or WhatsApp. Interviews will be scheduled at the participant’s convenient day and time. Interviews are anticipated to begin on 1 December 2020.

Patient and public involvement

No patients were involved.

Data analysis

We will transcribe and translate collected data into English language by listening to the audio recordings in order to conduct a thematic analysis. NVivo V.12 Plus software will be used to import, organise and explore data for analysis. Two independent researchers will read the transcripts at various times to develop familiarity and clarification with the data. We will employ an iterative process which will help us to label data and generate new categories to identify emergent themes. The recorded text will be divided into shortened units and labelled as a ‘code’ without losing the main essence of the research study. Subsequently, codes will be analysed and merged into comparable categories. Lastly, the same categories will be grouped into subthemes and final themes. To ensure inter-rater reliability, two independent investigators will perform the coding, category creation and thematic analyses. Discrepancies between the two investigators will be resolved through consensus meetings to reduce researcher bias.

Ethics and dissemination

Study participants will be asked to provide informed, written consent prior to participation in the study. The informed consent form can be submitted by the participant via WhatsApp or email. Participants who are unable to write their names will be asked to provide a thumbprint to symbolise their consent to participate. Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The study results will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

The findings of this study will help us to explore the perceptions and attitudes towards the COVID-19 pandemic and its impact on the daily lives and mental well-being of individuals in the community. Besides, an indepth understanding of the needs of the community will be identified, which will help us develop context-specific innovative mental health programmes to support communities in the future. The study will provide insights into how communities are managing their lives under such a difficult situation.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

ASF and NAA are joint first authors.

Contributors ASF and NAA conceived the study. ASF, NAA, RF, NA, SNM and SS contributed to the development of the study design and final protocols for sample selection and interviews. ASF and NAA contributed to writing the manuscript. All authors reviewed and approved the final version of the paper.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Information challenges of COVID-19: A qualitative research

Golrokh atighechian.

Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Fatemeh Rezaei

Nahid tavakoli.

1 Health Information Technology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Mitra Abarghoian

2 Vice-Chancellery for Research and Technology, Isfahan University of Medical Sciences, Isfahan, Iran

BACKGROUND:

At the beginning of the COVID-19 pandemic, the Iranian Ministry of Health and Medical Education set up a 24-h call center, i.e., Center 4030, to mitigate people's worries and anxieties, create composure, increase people's trust, and answer their questions. This qualitative study aimed to identify the challenges of COVID-19-related-information among people in point of experts' views.

MATERIALS AND METHODS:

This qualitative study was conducted to collect the opinions of experts on the identification of the Information challenges of COVID-19 during March–June 2020. The research population included all health professionals and experts. The sampling method was initially purposive and continued to saturate the data as snowball technique. In this study, 19 participants were interviewed. The data were collected using a semi-structured interview. After collecting the data, the audio files of the interviews were written down to extract their external and internal elements. MAXQDA version 12 software was used to organize qualitative analysis and coding data.

The results of this study involved eight themes, i.e., lack of planning, lack of social trust in government, lack of COVID-19-integrated scientific authority in the country, conflicts of interest, lack of integrated information sources, distracting public attention, infodemic, and poor information quality, classified into 16 categories.

CONCLUSIONS:

The main information challenges that people in Iran faced included the lack of a scientific reference source to access accurate information, the existence of a large volume of information in virtual networks, and a huge volume of statistics from various information channels that caused confusion among people.

Introduction

In general, any outbreak will be accompanied by a tsunami of information, which, unfortunately, most often includes misinformation and rumors as well. Moreover, this is significantly intensified in the current century due to the availability and ubiquity of social media. Obviously, getting the right information from a reliable source is a key issue in this type of pandemics.[ 1 ] “Access to the right information can save lives,” argues Zaimova, quoting the head of the World Health Organization (WHO).[ 2 ] In the recent COVID-19 pandemic, besides the challenges exerted upon the health system, the rapid dissemination of information, including false and misleading information about the disease, has had a major impact on the behavioral patterns of people in various communities. Therefore, community leaders and governments must take appropriate measures to ensure that people have access to reliable and relevant information about COVID-19. The head of the Atlantic Consulate, Wedelmann, acknowledges that scientists and other experts are the most reliable source of information, and governments and employers should call on them to obtain the most reliable information.[ 3 ] Evidence suggests that people unintentionally share false information about COVID-19, without thinking about its authenticity, based on various motives such as entertainment and attracting attention and approval on social media. Lack of transparency also leads to rumors, speculation, and misinformation.[ 4 ] Hua and Shaw stated that 44% of people were actively looking for reliable information, following the news, and putting their interests first, while 33% only passively digested information about COVID-19.[ 1 ] In this regard, the dangers of misinformation during the management of COVID-19 outbreak have been introduced with the term “infodemic.” Some experts believe that infodemic, i.e., too much information including right as well as wrong information, is spreading around the world. The worst-case scenario involves the fact that incorrect information is potentially released faster than the virus itself, causing people to make uninformed or misinformed decisions.[ 5 ] Therefore, there is the challenge of how people search for or avoid information. On the other hand, the unprecedented distribution of information on social media has provided people with access to a large amount of information. This has caused the spread of rumors and the dissemination of questionable information. As a result, this information conflict has led to the development of misinformation among people, as well as a negative impact on their behavior.[ 3 ] In addition, the psychological effects of misinformation on social media are significant. Therefore, if people cannot verify the accuracy of a large portion of information in cyberspace and the media, they will be anxious and worried. Therefore, it is necessary to draw their attention to the information that is published by official institutions and government agencies.[ 6 ] The WHO has said that misinformation has hampered the efforts of organizations and governments to control the spread of COVID-19. This makes it difficult to hear the voices of health-care organizations. Therefore, major attention and resources have been allocated to dealing with misinformation. Because the spread of this pandemic has been accompanied by a wide range of useless informational content, it has created new challenges.[ 7 ] While expressing his concern about the publication of false information about COVID-19, the head of the WHO admits that we are not fighting the coronavirus; rather, we are fighting the infodemic. Since false news and misinformation during this time will lead to misguided medical advice worldwide, the question is how to deal with such a serious problem.[ 8 ] In this regard, it is important for traditional and modern social media to help people have a better understanding of what they are looking for information about because these media are sometimes ahead of the evidence.[ 9 ] With the increasing use of social media and communication technologies, the infodemic challenge is growing,[ 10 ] and the sheer volume of online information is increasing people's anxiety. Therefore, it is imperative for the digital media platforms to be environmentally friendly and to create trust and calmness among people, especially when sharing information related to health and life threats.[ 11 ] On the other hand, many reliable sources, such as the WHO, are on social media, which can reduce people's anxiety by giving them access to the correct information while controlling the virus at the same time. Of course, the impact of the response to the infodemic varies depending on people's trust in the authorities and officials from one country to the other.[ 7 ] As the demand for access to reliable and timely information about COVID-19 increases in the community, policymakers need to be aware of the best practices for reducing the risk of the infodemic and turning to knowledge and expertise available in academic settings.[ 12 ] The wrong information is one of the great human challenges in the new COVID-19 crisis. Some people spend a lot of time reading-related information in print and virtual media. However, they are unable to distinguish quality information from false and low-quality information. This information reinforces the challenges, and people need to be equipped with the knowledge and skills of health literacy and media health literacy.[ 13 ] Academics and scientists need to pay attention to two basic aspects to share scientific information. These include filters that have the ability to increase the validity of data and the individual responsibility for creating and distributing information among people.[ 14 ] Information from all sources should be transferred to a dedicated COVID-19 center to discover, diagnose, treat, and most importantly, inform policymakers, investors, resource providers, affected populations, and social media. Reproduction and enhancement of misinformation must be prevented. In all scenarios, information must be at the level of understanding of the relevant community.[ 15 ] Over the past 2 months in Iran, people have faced many challenges due to concerns about the spread of COVID-19 because of the spread of large amounts of scattered and disorganized information on social media from domestic and foreign sources. This has exacerbated their concerns and confusion about conscious decisions on this disease's prevention and care. On the other hand, the repeated recommendations of the media and the retelling of the decisions and actions of the officials, which were sometimes inconsistent and contradictory, led to the intensification of mental fatigue and confusion of the families.[ 16 ] At the beginning of this pandemic, the Iranian Ministry of Health and Medical Education set up a 24-h call center, i.e., Center 4030, to mitigate people's worries and anxieties, create composure, increase people's trust, and answer their questions. The main objective of this call center has been to answer ambiguities and prevent rumors.

However, despite the implementation of this important step, people are still resorting to various sources to obtain information in the face of numerous information challenges related to the coronavirus, and this qualitative study has been designed to identify them.

Materials and Methods

Study Design and Setting: In this study, a qualitative study was conducted to collect the opinions of experts on the identification of the information characteristics and challenges of COVID-19 during March–June 2020.

Study participants and sampling: The research population included all health professionals and experts, including university faculty members, policymakers, university administrators and experts and physicians, nurses working in the infectious diseases unit. The sampling method was initially purposive and continued to saturate the data as snowball technique. First, five participants were selected who had experience or knowledge about the main phenomenon or basic concepts explored. In this regard, to access different opinions about the central phenomenon and the explored concepts, the sampling with maximum diversity was performed, and people with different views were selected. Sampling continued until data saturation. In this study, 19 participants were interviewed. Inclusion criteria consisted of all professionals, policymakers, managers, and experts with at least 5 years of experience. Furthermore, individuals who refused to be interviewed were excluded.

Data Collection Tool and Technique: The data were collected using a semi-structured interview. To verify the validity of the interview guide, the interview questions among the research team were first discussed with the participation of one external expert and revised accordingly. The interview guide was subsequently tested on three nonparticipants to check the number and order of the questions in the study. It is achieved by analyzing and comparing the contents of the interview until no new or appropriate details concerning a theme appear to emerge.

The time and place of the interview were prearranged with the participants, preceded by obtaining their permission through an informed consent form. The interviews were recorded through a voice recorder. Due to the prevalence of corona, some interviews were conducted by phone. After collecting the data, the audio files of the interviews were written down to extract their external and internal elements.

MAXQDA Plus version 12 software (Release 12.3.0, VERBI GmbH Berlin) was used to organize qualitative analysis and coding data. For the evaluation of the reliability of the study data, four criteria were used in Lincoln and Goba, namely, credibility, conformability, dependability, and transferability (Lincoln YS and Guba EG, 1985).

Ethical consideration: This study received the required ethics approval from Isfahan University of Medical Sciences Research Ethics Committee, Isfahan, Iran, with ethics code No. IR.MUI.MED.REC.1398.653.

More than half of the participants were male (63.1%), and the majority had a PhD (42.1%). Furthermore, more than half of the participants (52.6%) had more than 20 years of experience [ Table 1 ].

Basic characteristics of participants

The results of this study involved eight themes, i.e., lack of planning, lack of social trust in government, lack of COVID-19-integrated scientific authority in the country, conflicts of interest, lack of integrated information sources, distracting public attention, infodemic, and poor information quality Table 2 , classified into 16 categories.

Information challenges regarding COVID-19

Lack of planning

Lack of planning involves invalid information and a lack of consistency in informing the public.

Participants believed that invalid information and instability in information-related decisions were indicative of the authorities' lack of planning in the COVID-19 outbreak. The confusion of health policymakers in the decision-making process, the government's different decisions to declare closures for different jobs, and the variable decisions of managers were among the issues that the participants referred to.

The Ministry of Health and Medical Education and the health authorities do not have specific credible channels and entries, so weaknesses and conflicts are transferred to the community, then their authority is destroyed, and people lose confidence in official sources (Interviewee 5).

The reasons for the officials' lack of planning in this pandemic involved managers' changing decisions, people's confusion about whether COVID-19 was getting serious or not, lack of foresight and preparedness of the government to guide people, failure to implement preventive measures to mitigate the confusion of people, and politically ignoring the support and experience of other countries.

Due to the fact that the news and information about the Coronavirus unfortunately reached the people very late, the members of the community partially underestimated the epidemic, and no training was provided (Interviewee 1).

Lack of social trust in government

This involved lack of transparency from the officials in informing people, and a lack of trust on the part of people due to authorities downplaying the seriousness of the crisis. The government's secrecy in providing information about the number of deaths and infections led to people shifting their attention and trust to unofficial channels, which was a sign of their lack of social trust.

People's attention and trust in unofficial channels was expressed as one of the signs of social distrust. People always think that the government is hiding the facts from the foreign channels or from other media, that is, we have a kind of unhealthy atmosphere (Interviewee 1).

Participants cited a lack of transparent information in the early days of the epidemic and lack of timely information as some of the reasons for people's distrust.

The more realistic and transparent we talk to people, the more we can gain people's trust. People traditionally trust centers that have long been among their safe havens. Well, naturally, medical centers are one of these centers (Interviewee 10).

The lack of transparency in the statistics was another reason for people's distrust.

For example, even in the case of statistics, it is not yet clear whether the statistics are real or not. Even if they weren't real, it would definitely be a good reason behind it that I don't want to talk about. There is probably a reason, and I have to admit, they don't want to announce the actual statistics (Interviewee 2).

Lack of COVID-19-integrated scientific authority in the country

This theme includes a lack of consistency of published information and various media and informational sources. The lack of an integrated scientific reference led to parallel work, lack of consensus among experts on some scientific topics, and information confusion when comparing multiple information sources.

Recently, The Islamic Republic of Iran Medical Council has been working for itself, which is, in my opinion, wrong. All of this must be centralized, and in fact we must have a position of information management under the supervision of the Ministry of Health and Medical Education. All material produced must first be approved by the Ministry of Health and Medical Education, and then reach the public (Interviewee 17).

Conflicts of interest

This included disagreement between officials and disregard for different specialties. Lack of consensus among authorities and ignoring the different specialized opinion of experts led to conflicts of interest.

Every organization considers its own interests and does not value us (the Ministry of Health and Medical Education). They do not follow government orders, even if it is to their detriment. Therefore, providing information under these conditions will not be effective (Interviewee 1).

The multiplicity of nontechnical spokespersons in the national media and noncompliance with professional privacy were some of the issues raised by the participants.

Well, I don't know what's behind the scene. But when we hear and compare their official statements, there are all kinds of conflicts in the policies and words of health policymakers (Interviewee 5).

Lack of integrated information sources

This category included parallel information provision streams from the media and a lack of valid information provision channels. The existence of multiple telephone lines multiple websites created by different individuals indicated a lack of an integrated information source in the country.

One organization said we would give people a phone number, another said we would create a website. However, everyone wants to have an information channel (Interviewee 2).

Lack of knowledge about where to go for information and parallel work in informing indicated the lack of an integrated information source in the country.

People don't know where to get information and which information source to trust. Well, the existence of social networks makes information available to the public, but the important thing is to trust our own mass media or a foreign media (Interviewee 11).

Distracting public attention

This category included provoking people through cyberspace, speculations caused by following the cyberspace information sources, easy access to unreliable sources and virtual networks, misuse of virtual networks by profiteers, each person having a tribune in the cyberspace, and increasing public concern by foreign channels.

I spend almost 90% of my time dealing with and denying false news. Sir, this is not true, sir, this is not true, sir, this is not true, and then the one I can say is right is what the Ministry said. So it is better, at least for ourselves, to have the unity of voice as always (Interviewee 3).

The gap between the data reported by the government and that reported by foreign media on the disease has raised concerns.

If people are given regular statistics, their fears will be reduced (Interviewee 3).

This category included a wide dissemination of information and diffusion of false information. From the participants' point of view, the high volume of available information and the anarchy of information in COVID-19 caused anxiety and confusion among people.

The most important problem, in my opinion, is that people are confused about information, that is, they have become so bombarded with information that they can't really decide what to do (Interviewee 10).

The availability of multiple sources of information, the dissemination of false news on virtual networks, and lack of information refining have prevented people from distinguishing between right and wrong information.

Valid and reliable information must be given to people. People receive general information about COVID-19 from various media outlets, but they do not have the same information about necessary actions, such as disinfecting surfaces. One source says make Javelle water and bleaching solution with a ratio of 1:4. Another source says make it with a ratio of 1:49, another says make it with the ratio of 1:100. Individuals and/or organizations give different instructions (Interviewee 17).

Poor information quality

This category included disinformation, contradictory information, limited access to information, and misinformation. Lack of access to accurate and comprehensive information about the disease and the lack of accurate statistics on the number of infected individuals have caused concern.

We do not have accurate statistics. We don't know how many patients we have, how many samples have been sent, how many have been positive and how many have been negative. This causes fear and panic among people (Interviewee 14).

Participants acknowledged that the spread of rumors and false news by virtual networks has accelerated the dissemination of low-quality and misleading information.

At present, the media and social networks in the country have spread false information among people by spreading rumors in the community. Of course, there are reasons why we may have caused this (Interviewee 7).

Appropriate behavioral patterns among authorities and the public in epidemics regarding the production and distribution of information in various media are very helpful in promoting public awareness and knowledge for the prevention of epidemics.[ 17 ] In the present study, participants believed that provided medical information should be organized, simple, and fluent and in a language that is easy to understand by ordinary people to reduce concerns and anxieties of people. As many behavioral fears and reactions naturally arise from a lack of knowledge, rumors, and misinformation, providing clear, concise, and accurate information about COVID-19, and user-friendly ways to access such information reduce the public's focus on rumors.[ 18 ] According to the participants' views, multiple instructions from different universities, the presence of multiple articles and longwinded instructions, and the presence of multiple sources of information that must be compared have led to confusion. Moreover, they emphasized that people must refer to reliable information sources such as the website of the Ministry of Health and Medical Education, doctors' inquiries, the National Broadcasting Media, and trustworthy online news, to reduce their worries about the virus and to prevent being infected with misinformation. The WHO states that insufficient information about the coronavirus increases the likelihood of mistrust in government and authorities. In addition, this organization recommends searching for information from reliable sources, such as radio and television, and national newspapers, once or twice a day instead of once every hour, helping people manage and reduce their stress.[ 19 ] As worst-case scenarios are usually accelerated when there is no information, leaders should provide the most up-to-date information about COVID-19 for health workers to know how to protect themselves and what to do if they encounter it. In addition, the leaders should anticipate what questions might arise and prepare their answers well. In this way, they are empowered with reliable information so that they can help themselves and control their stress.[ 20 ] In their study, Stirling et al . found that 66.4% and 55.3% of medical students depended on the internet, and television and radio for getting coronavirus information, respectively.[ 21 ] Participants in the present study acknowledged that a lack of clear information and normalizing the prevalence and risk of the disease by the radio and television channels at the beginning of the epidemic, lack of transparency in the statistics provided to the public, provision of politically biased information, government secrecy and untruths, rumors, and dissemination of various pieces of false news in virtual media led to people's concern and confusion in obtaining accurate and reliable information. The findings of the present study were consistent with Baines study, showing that a lack of transparency and delay in public urgency led to fears among the health authorities and delays in disclosing information about COVID-19, spreading misinformation and rumors among the public, incorrect public forecasting, ultimately causing the unexpected dissemination of the virus.[ 22 ] Moreover, the findings of the present study were in line with those of Dong's study, showing that downplaying the severity of the epidemic of COVID-19 by the Chinese government in the early days caused people's distrust in the transparency and the decision-making capability of the government.[ 23 ] In the present study, according to the participants' views, the infodemic phenomenon led to people's confusion. In this regard, the presence of numerous information sources, the high volume of available information, people's anxiety caused by information anarchy, information redundancy, lack of information refining and cleaning instruments, and the misrepresentation of news in virtual networks were mentioned as examples. Lu's study showed that infodemic, including incorrect information about COVID-19 on social media and elsewhere, caused a major risk to people's mental health during this crisis.[ 23 ] In his study, Bains emphasized that, in order to fight infodemic, it was necessary to analyze all types of information, to have an integrated scientific approach, to have a clear and scientific definition of all types of information, and to avoid using wrong words.[ 22 ] The findings of the current study showed that provoking people through virtual networks, speculation due to following cyberspace channels, easy access to unreliable sources in virtual networks, and the misuse of virtual networks by profiteers were significant challenges people encountered. Allah Verdi believes that there is a difference between producing and disseminating COVID-19 health messages and disseminated unprofessional messages on social media. Hence, in order to break the chain of disease transmission, it is necessary for the health system to take measures to prevent the spread of misinformation.[ 24 ] Kouzy et al . analyzed 673 tweets and showed that the least amount of unconfirmed information was related to public health accounts and accounts of health-care services, while the most misleading information was related to personal and group accounts. Another noteworthy point in her study was the lower incidence of misinformation when searching the literature using COVID-19 instead of 2019_ncov and corona. She believes that incorrect medical information and a lot of unconfirmed content about COVID-19 are being widely published on social media, and it is necessary to intervene in this process to protect public safety.[ 25 ] The other challenges mentioned in the present study involved promoting people's awareness in an unfair environment structured around mistrust, higher levels of trust on the part of people in social media than mass media, people's distrust of official information sources, failure to take the virus seriously, failure to inform people by the national media, lack of managers' ability to attract public cooperation and trust, failure to provide timely information, and secrecy in reporting the number of COVID-19 deaths and patients. In her study, Sharma emphasized that the health-care organizations and other authorities should develop practical strategies for identifying credible and reliable information sources and disseminating valid information about COVID-19. In addition, she argues that, using scientific methods, such as data mining, for identifying and removing those messages in virtual networks which have no scientific evidence behind them is one of the legal measures that can be taken.[ 26 , 27 ] In the current study, provision of contradicting content from different sources; obtaining information from invalid sources, which creates anxiety; lack of a reputable reference source to answer all relevant questions; contradiction between official media news and social networks; availability of information from multiple and contradictory channels; and lack of knowledge on where to go for reliable information were among other challenges noted by the participants. Hua described the reasons of China's success in controlling COVID-19 as a strong government, implementing restrictions, and people's immediate participation. In the early stages, the highest judicial authority's guidelines on false news constituted an important step toward reducing confusion and panic among people.[ 12 ] In Medford's study, about half of the tweets scared people and about 30% were surprising them, among which the political and economic impacts of COVID-19 were the most important discussion topics.[ 28 ]

Shankar pointed out that one of the challenges for medical staff in dealing with cancer patients, who wanted to find accurate information to adapt to the conditions of COVI-19, was the existence of a large volume of information on virtual networks.[ 29 ] Health ministries and health education specialists in various countries should design an interactive dashboard to deal with the release of huge amounts of inaccurate information and misinformation, provide real-time information, and eliminate rumors related to COVID-19 around the world.[ 24 ] In his study, Bastani emphasized that health department's managers should have practical perspectives on managing public information in the community.[ 30 ]

Conclusions

With the COVID-19 pandemic, information seeking, especially on social media, emerged as one of the major challenges facing the affected communities. In this regard, the large volume of information and the lack of a reliable source to obtain accurate information, especially in the early days, caused concern and anxiety among people. In this study, the main information challenges that people in Iran faced included the lack of a scientific reference source to access accurate information, the existence of a large volume of information in virtual networks, and a huge volume of statistics and detailed news from various information channels that caused confusion among people. Therefore, considering the fact that epidemiological predictions show the high likelihood for the continuation or re-spread of this virus, it is recommended that health leaders identify and/or introduce a scientific authority for information related to COVID-19 in the country; introduce reliable information sources; provide simple, legible, and transparent information; and encourage people to improve their knowledge so that they can correctly interpret the right information, and keep themselves and their families safe from the virus.

Financial support and sponsorship

This study was funded by Isfahan University of Medical Sciences, Isfahan, Iran, with research code No. 198222.

There are no conflicts of interest.

Acknowledgments

We would like to thank all interviewees for their kind contribution. Moreover, the authors cordially appreciate Dr. Hasan Ashrafi-Rizi for his kind help and guidance.

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Qualitative study of the psychological experience of COVID-19 patients during hospitalization

Affiliations.

• 1 Humanities Teaching and Research Office, School of Nursing, Henan University of Science and Technology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China.
• 2 Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
• 3 Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China. Electronic address: [email protected].
• 4 Department of Infection, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China. Electronic address: [email protected].
• PMID: 32949869
• PMCID: PMC7444461
• DOI: 10.1016/j.jad.2020.08.040

Background: Coronavirus disease 2019 (COVID-19) continues to spread across the globe, but patient experiences are rarely documented.

Objective: To explore the psychology of COVID-19 patients during hospitalization.

Methods: A phenomenological and robust sampling approach was employed. Sixteen patients admitted to the First Affiliated Hospital of Henan University of Science and Technology with COVID-19 from 20th January to 1st March 2020 were selected. Data were collected through semi-structured interviews, phone calls, or face-to-face interviews using quarantine measures. Data were analyzed using the Colaizzi method.

Results: The psychological experience of COVID-19 patients during hospitalization could be summarized into five themes. Firstly, attitudes toward the disease included fear, denial, and stigma during the early stages, which gradually developed into acceptance in the later stages. Secondly, the major source of stress included the viral nature of the disease, quarantine measures, and concerns regarding the health of family members. Thirdly, reactions of body and mind included disease stage-dependent emotional responses, excessive attention to symptoms, rumination, and changes in diet, sleep, and behavior. Fourthly, supportive factors included psychological adjustments, medical care, and family and social support. Finally, the disease resulted in psychological growth and patients viewed problems with gratitude through the cherishing of life, family, bravery, and tenacity.

Conclusion: COVID-19 patients gradually changed their attitude toward the disease and displayed emotional responses dependent on the stage of the disease. Negative emotions dominated during the early stages but gradually gave way to mixed positive and negative emotions. Active guidance of psychological growth may therefore promote physical and mental recovery in COVID-19 patients.

Keywords: Coronavirus disease 2019; Emergencies; Pandemic; Patients; Psychological experience; Qualitative study.

Copyright © 2020. Published by Elsevier B.V.

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