key: cord-0815155-nqkn6htw
authors: Munawar, Khadeeja; Choudhry, Fahad Riaz
title: Exploring Stress Coping Strategies of Frontline Emergency Health Workers dealing Covid-19 in Pakistan: A Qualitative Inquiry
date: 2020-07-07
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.06.214
sha: 8b840aedb2b57f7944f78684dbbda46e736a1034
doc_id: 815155
cord_uid: nqkn6htw

BACKGROUND: The COVID-19 outbreak has gravely impacted the physical and psychological health of people. As the outbreak is ongoing, it is crucial to equip the emergency healthcare workers (HCWs) to be medically and psychologically prepared. OBJECTIVE: To examine the psychological impact of COVID-19 on emergency HCWs and to understand how they are dealing with COVID-19 pandemic, their stress coping strategies or protective factors, and challenges while dealing with COVID-19 patients. METHOD: Using a framework thematic analysis approach, 15 frontline emergency HCWs directly dealing with COVID-19 patients from 2 April to 25 April 2020. The semi-structured interviews were conducted face-to-face or by telephone. Data were analysed using thematic analysis. RESULTS: Findings highlighted first major theme of stress coping, including, limiting media exposure, limited sharing of Covid-19 duty details, religious coping, just another emergency approach, altruism, and second major theme of Challenges includes, psychological response and noncompliance of public/denial by religious scholar. CONCLUSION: Participants practiced and recommended various coping strategies to deal with stress and anxiety emerging from COVID-19 pandemic. Media was a was reported to be a principal source of raising stress and anxiety among the public. Religious coping as well as their passion to serve humanity and country were the commonly employed coping strategies.

The beginning of 2020 brought a new challenge for the mankind the coronavirus disease 2019 . This virus, having origins in the Wuhan city, gradually spread throughout China and became a global health threat (1, 2) . So far, the COVID-19 is considered the largest outbreak of atypical pneumonia since the severe acute respiratory syndrome (SARS) epidemic which occurred in 2003 (3) . Contrary to the SARS, the total number of cases and death toll due to the COVID-19 became much higher following weeks of the initial outbreak (4) . The epidemic was initially detected in December 2019, when number of pneumonia cases of unspecified aetiology were noticed to be linked with epidemiologically related contact with a seafood market and untraced contacts in the city of Wuhan of Hubei Province (5) . By late January 2020, the number of cases and death toll due to the COVID-19 escalated exponentially within and beyond Wuhan and spread to all 34 regions of China. Hence, based on the impact, the COVID-19 outbreak was declared by the World Health Organization (WHO) a public health emergency of global concern (6).

In Pakistan, on February 26, 2020, the first case of COVID-19 was reported in Karachi (7) .

According to the Ministry of National Health Services Regulations & Coordination department of Government of Pakistan (GoP), the virus steadily spread to other regions of the country and within a span of few days, the confirmed cases due to COVID-19 rose to 56, 386 . However, 19 ,142 individuals recovered and there were 1,225 deaths due to this virus (8) .

Past studies have investigated the epidemiology and clinical characteristics of infected patients (9, 10) , the genomic features of the virus (11) , and issues for global health governance (12) . Presently, there is limited information related to the psychological impact and mental health of people during the COVID-19. Such an information is particularly significant amidst the ambiguity surrounding an epidemic of such an unmatched magnitude.

A study investigating psychological responses and associated factors during the initial stage of the COVID-19 in general public demonstrated moderate to severe psychological impact as well as moderate to severe depressive, stress and anxiety symptoms (3) . Availability of updated health information and particular precautionary measures were shown to be linked with reduced psychological impact of the outbreak and reduced levels of stress, anxiety, and depression (3) .

During the times of epidemics, most of the public health authorities and media predominantly are focusing on biological and physical consequences of the outbreak, thus, a reduced attention is paid to the mental health issues. Nevertheless, with the growing mental health burden during the COVID-19 epidemic, the calls for improved mental health support have escalated. For instance, in China, thorough guidelines for emergency psychological crisis intervention for people influenced by COVID-19 were issued by the National Health Commission on 27 January (13). These guidelines stressed the need for multi-disciplinary mental health teams to provide mental health services to patients and Health Care Workers (HCW).

As the outbreak is ongoing, it is crucial to equip the health care systems and the general public to be medically and psychologically prepared (14) . Past studies have shown that HCWs (e.g., paramedics, ambulance personnel, and other HCWs) who were at high risk of exposure of infectious disease outbreak exhibited extreme stress, were emotionally influenced and traumatized, and had extreme levels of symptoms of depression and anxiety (15) . This is anticipated because the anxiety and fear of being infected is greater with the risk of exposure.

There may also be a fear of transmitting infection to their significant others. In majority of HCWs, conflicts and dissonance were shown to emerge as a result of trying to balance professional responsibility, altruism and personal fear for oneself and others (16) .

A higher susceptibility of developing adverse psychiatric issues has been shown in HCWs serving in emergency departments, intensive care units, and isolation wards compared to those working in other departments, probably because they are directly exposed to the infected patients, and their work is more challenging (17) . Likewise, it was shown that as compared to married professionals and nurses; doctors and single professionals were more vulnerable to psychiatric issues (18) . A current systematic review on the influence of disaster on mental health of HCWs showed absence of social support and communication, maladaptive coping, and absence of training as common risk factors for developing psychiatric issues (17) .

Although isolation strategies (e.g., social distancing) are adopted globally to minimize the spread of the COVID-19, such strategies are only assisting in protecting lives. Isolation may add to the stress and is very likely to cause psychiatric issues (19) . The past evidence from Cognitive Behaviour Therapy (CBT) paradigm emphasises the need to build resilience (20) . Resilience is the ability of a person to recover swiftly from hardships and people using positive emotions in difficult situations have been found to be resilient (21) . Past literature shows that extremely resilient people foster their positive emotions which assist them in dealing with stress, boredom, and change (21) . Resilience helps in coping with mental and physical health issues, thus, it can act as a protective factor against the onset of psychiatric issues among those facing hardships (22, 23) . Similarly, a systematic review demonstrated negative relationship between resilience and common mental disorders and an association of resilience with health promoting behaviour and quality of life (24) . However, there is limited knowledge about factors that buffer the negative impact of perceived severity on frontline emergency HCWs' mental health. Based on the risk-resilience model (25) , it is proposed that self-control (i.e., a person's ability to reverse or change inner reactions and to suspend undesired behavioural tendencies) may act as buffer against the negative influence of perceived severity of the COVID-19 and mental health problems among people (26) .

The COVID-19 outbreak has gravely impacted the physical, psychological health and lives of people. It has resulted in various psychiatric issues, for instance, panic disorder, anxiety, and depression. However, no research articles have examined the psychological impact of COVID-19 on the emergency healthcare workers in Pakistan so far; a country having steadily rising confirmed cases and deaths (37). Additionally, the HCWs in Pakistan have been reported to be ill-equipped to deal with the COVID-19 (38) . Hence, the main purpose of the present study is to understand how emergency healthcare workers are dealing with COVID-19 pandemic, and what are their stress coping strategies or protective factors against stress eventually contributing to their mental health, and challenges they are facing while dealing with COVID-19 patients. This study will, consequently, offer a concrete basis for adapting and executing appropriate mental health intervention policies to cope with this challenge efficiently and effectively. This may help government bodies and healthcare professionals in preserving the psychological wellbeing of the HCWs in the face of COVID-19 outbreak in Pakistan and various parts of the world.

This qualitative inquiry used framework thematic analysis approach and made an initial attempt to explore COVID-19 related protective factors and coping mechanisms among emergency frontline HCWs in Pakistan. Thematic analysis is an interpretive procedure, in which data is methodically examined to find patterns within the data to offer a revealing account of the phenomenon (39) . This method helps in forming meaningful themes without clearly creating theory (40) . This method has been used to generate rich and comprehensive conception of complex phenomena (41) . Both authors independently read data multiple times to extract and code any themes related to the research objective.

Through the convenience sampling method, 15 frontline emergency HCWs directly dealing with COVID-19 patients were recruited between 2 April to 25 April 2020. Advertisements to recruit participants were shared on different social networking sites. The inclusion criteria included (1) frontline emergency HCWs who directly dealt with the COVID-19 patients (i.e., shifted them from their homes, local hospitals and other places to COVID-19 wards/centres), and (2) volunteers who participated in the study. The exclusion criteria were not consenting to participate or withdrawing from the study during the conduction of interview or one week after the interview. Initially, twenty participants consented to be part of the study, however, five of them refused due to some personal reasons. The final sample consisted of fifteen participants (Table 1 ) who were ensured of the confidentiality and anonymity. The rapport building sessions comprised of sharing purposes of the study with participants before interviews.

The outline of interview protocols was designed by going through past literature, discussing with experts of qualitative research as well as conducting some pre-interviews with frontline HCWs. The interview protocols also included probes for the actual question (i.e., how do you see the COVID-19 in Pakistan/what is your perception about the COVID-19 in Pakistan?). The interviews were conducted in a national language (i.e., Urdu) of Pakistan in which the researcher and participants both were comfortable in sharing their perspectives.

The qualitative interviews were conducted after participants read and understood the explanatory statements as well as signed written informed consents. The interviewer possessed a PhD in Psychology degree with ample experience in qualitative interview and had worked on numerous qualitative research projects on resilience and protective factors of various communities. Additionally, the interviewer was a well-versed clinical psychologist with almost 10 years' experience of evidence-based practice, teaching, and scientific research. Hence, the researcher was able to conduct this research.

The locations of conducting interviews were chosen based on the ease and convenience of each participant. A relaxed setting, comprising two chairs and a small table between each participant and interviewer, was maintained. The interviews were recorded, which were kept strictly confidential. Additionally, personal space was ensured to listen to participants clearly without interfering in their space. The room where interviews were conducted quiet, had minimal distractions, sufficient lightning, and adequate temperature. The emergence of similar responses after fifteen interviews showed acquisition of data saturation, hence, no further interviews were conducted. Each interview took approximately one hour.

Additionally, participants were requested to pause interview and take a break or prevent further interviews in case they experienced emotional distress/discomfort during the interview.

In case of emotional distress/discomfort, they were provided a list of counselling services which provided free of cost psychological help, however, none of the participants displayed any distress. Participations in this study was voluntary and participants were under no obligation.

They could draw from the study from it began, during the interviews were conducted or one week after the data had been collected. The researchers maintained an unbiased stance while conducting interviews and kept amiable relationship with the participants. Before conducting actual interview with each participant, one or two rapport building sessions were conducted.

After recording interviews, transcription process began, and the data were subsequently analysed through thematic analysis approach.

Braun and Clarke (2006) have recommended various ways of transcription based on the analytical methods. Orthographic transcription was done, and it consisted of a "verbatim" account of all verbal as well as non-verbal expressions. Hence, all the verbal, and non-verbal responses were written down. Analysis were performed by both authors independently. They read the transcript multiple times, condensed, and obtained meaningful statements, and devised the themes and sub-themes. The discrepancies between both authors were settled through mutual discussion and a consensus was reached. This process was done independently of findings from any past studies. To analyse data as well as to maintain anonymity of participants, numbers were assigned to each participant.

The study was conducted in accordance with the Ethical Standards of the 1964 Helsinki Declaration and its Later Amendments or Comparable Ethical Standards. Written informed consent was obtained from all participants as well as participants consented for the findings to be published. Additionally, formal approval was taken from the concerned authorities for data collection. The authors ensure that there was no academic misconduct such as plagiarism, data fabrication, falsification, and repeated publication.

The sample comprised of 15 males between 28 to 38 years of age with a mean age of 31.87 ±2.82. The working experience ranged from 2 to 12 years with a mean of 6.53 ± 2.44. the minimum qualification of the participants was a secondary school certification. Table 1 shows the participants' characteristics. 

Participants also highlighted their significant coping mechanism of not revealing detailed information regarding the duties they have performed in dealing with COVID-19

patients. Participants believed that sharing of such information may increase vulnerability of their significant others and exacerbate their anxiety and fear related to COVID-19. 

An important theme extracted from the data is religious coping. Considering the data from Muslim participants, religious coping was one of the significant themes. The faith-based practices and belief system is seen to play an integral role in lives of the selected sample to cope with the pandemic of COVID-19. Some of the excerpts are shared: 

This is a noteworthy theme reflecting the high regard of religious values and faith among participants. Since, the participants are using religious coping and put emphasis on their faith in order to deal with challenging situations such as pandemic, it can be concluded that faith/religion could be an element of resilience for the selected participants and served as protective factor.

Some of the participants shared their coping of dealing with COVID-19 related stress by conceptualizing it as just another emergency, as they are trained for a wide range of emergencies.

They seemed to normalize their stress by recalling their nature of duty and reminding themselves that it is not the first time they have dealt with threatening events. The way participants neutralized/ normalized the actions of performing the special duties of dealing with Covid-19 patients and reflected their sense of responsibility in the quotes above, shows their motivation and professional attitude to not only fulfil their job responsibilities but also to serve humanity.

Most of the participants shared that their reasons to enter this profession of emergency health provider services was their passion to serve humanity and they have reflected empathetic attitude toward 

Another theme extracted from the data is public's noncompliance with the instructions issued by the Government to fight COVID-19. According to participants, people were not abiding by the instructions and worsening the situation. The participants shared in following words: 

This study was conducted to understand how emergency frontline HCWs in Pakistan directly dealing COVID-19 patients are interpreting their experiences and what stress coping strategies they are employing. The findings of thematic analysis revealed that participants practiced and recommended various coping strategies to deal with stress and anxiety emerging from COVID-19 pandemic. For instance, participants shared that media was a principal source of elevating stress and anxiety among the public. Additionally, it was revealed that there was no way to confirm the authenticity of updates or news shared across various media which was adding to the uncertainty in this pandemic. Findings of past studies have also shown the role of media in exacerbating mental health issues (42) (43) (44) . Studies have also demonstrated the role of televised traumatic content among general public in developing distress posttraumatic psychopathology (45) . Likewise, participants also disclosed limited details about their work schedules to protect their significant others from any distress or anxiety. This limited self-disclosure to prevent distress among significant others was also documented in studies conducted on patients with HIV (46) (47) (48) .

Religious coping, their passion to serve humanity and country were also frequently employed coping strategies. These findings resonate with previous literature on healthcare workers about commitment to their profession as a primary motivation to continue to work (49) (50) (51) . In harmony with past studies, by attributing religious meaning to the COVID-19

pandemic, participants were strengthening their coping (52) (53) (54) (55) . Additionally, in contrast to avoiding responsibilities as shown in past studies (51, 56) , participants in the present study were willing to perform their duties even amidst the COVID-19 outbreak and considered it as another emergency. In line with the past studies (57) (58) (59) , participants' willingness to respond in uncertain and insecure situation of COVID-19 were their beliefs in duty, positive opinions and views regarding their roles during the pandemic which also influenced their resilience and coping mechanisms.

Similar to past studies, participants of present study acknowledge some fear and anxiety due to uncertain conditions (60, 61) . However, resilience and managing emotions appropriately drove participants to continue working. Participants also shared their concerns about non-compliance of the public and revealed that such behavior from the community was 

This study in one of the initial attempts to explore the coping mechanisms and challenges of frontline HCWs in Pakistan in relation to COVID-19. Most of the prevailing qualitative studies are retrospective in nature, contrarily, this study was conducted in earlier stage of pandemic. Additionally, instead of just conducting interviews directly, a few rapport building sessions were conducted with each participant to familiarize them with the interviewer as well as the purpose of the study. This resulted in a thorough comprehension of participants' experiences. Contrary to the findings of past studies, the participants of present study demonstrated a variety of coping strategies/protective factors that were buffering against the challenges of COVID-19 pandemic.

There are some limitations of this study. The study was carried out when the pandemic was ongoing and we were conscious of not distracting the participants from essential work, hence, interviews were often paused or interrupted because the participants had to attend some other emergency calls and duties. Due to qualitative nature of study, the findings lack generalizability, and only explore the perspectives of emergency frontline HCWs.

Consequently, it cannot disclose other perspectives, such as those of other HCWs, administrators, community members, and patients. Furthermore, we were conscious of social/physical distancing guidelines enforced by the government, hence, focus group discussions could not be conducted. Sample was also kept small owing to the exploratory nature of the study. This study did not report findings of HCWs from private facilities who may have different experiences of the pandemic and different coping mechanisms, which need exploration. The study used thematic analysis approach; thus, it may not capture the depth in analysis and only reported the themes analysed for semantic and latent meanings. In a similar future studies, a more in-depth approach such as phenomenology or grounded theory could be employed for additional linguistic analysis of the data.

Although the authors have prior experience of conducting qualitative studies and using multiple data collection methods including semi-structured interviews, focus group discussions, and ethnographic observation, the data collection during the pandemic was challenging task, especially ensuring the social distancing and all the precautionary measures for the study participants and the research assistant collecting data. The authors recruited a research assistant who has adequate experience of interviewing and already working in the health sector; thus, a separate research gatekeeper was not required.

This study presented a thorough and in-depth understanding of how the frontline emergency HCWs are dealing with COVID-19 pandemic, their stress coping strategies, or protective factors, and challenges while dealing with COVID-19 patients through thematic analysis method. It was found that during the pandemic, media was mentioned to be a major source of exacerbating anxiety and stress levels of masses as authenticity of updates or news shared could not be ascertained. Furthermore, religious coping, passion to serve humanity and country, considering this pandemic just an emergency, as well as positive opinions, and views regarding their roles during the pandemic boosted their resilience and coping mechanisms. The findings suggest launching of massive and prolonged public awareness programs to improve the information of the general population, aiming on mode of transmission, and situation-specific preventive strategies along with tackling mistrust, myths, and misconceptions. Health systems strengthening should be promoted by providing frontline

HCWs with essential information about available mental health services to improve their selfesteem, resilience, and capability of HCWs to respond to the pandemic. Additionally, findings serve as a reference and inspiration for future mental health research studies on 

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The study was conducted in accordance with the Ethical Standards of the 1964 Helsinki Declaration and its Later Amendments or Comparable Ethical Standards.

Written informed consent was obtained from all participants as well as participants consented for the findings to be published. Additionally, formal approval was taken from the concerned authorities for data collection.

The data that support the findings of this study are available from the corresponding author [FRC], upon reasonable request.

Code availability (software application or custom code): Not applicable

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