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Exploring Stress Coping Strategies of Frontline Emergency Health Workers Dealing
Covid-19 In Pakistan: A Qualitative Inquiry
Background: The COVID-19 occurrence has gravely affected the physical and psychological
health of individuals. As the pandemic is current, it's crucial to equip the emergency health care
staff (HCWs) to be medically and psychologically ready.
Objective: to look at the psychological impact of COVID-19 on emergency HCWs and assess
however they are addressing COVID-19 pandemic, their stress coping methods or defense
factors, and challenges while addressing COVID-19 patients.
Methods: employing a framework thematic analysis approach, fifteen frontline emergency
HCWs directly dealing with COVID-19 patients from April 2, 2020 to April 25, 2020. The semistructured interviews were conducted face-to-face or by phone call. Collected information was
analyzed using thematic analysis.
Results: Findings highlighted 1st major theme of stress coping, including, limiting media
exposure, limited sharing of Covid-19 duty details, religious cope, simply another emergency
approach, altruism, and second major theme of Challenges includes, psychological response and
rebelliousness of public/denial by spiritual scholar.
Conclusions: Participants practiced and suggested varied header methods to cope with stress and
anxiety rising from COVID-19 pandemic. Media was reported to be a principal supply of raising
stress and anxiety among the general public. The religious coping additionally as their passion to
serve humanity and country were thecommonly used coping methods.
Key Words: Coronavirus disease 2019 Epidemic outbreak Frontline health workers Qualitative
study.
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Exploring Stress Coping Strategies Of Frontline Emergency Health Workers Dealing
Covid-19 In Pakistan: A Qualitative Inquiry
COVID-19
The beginning of 2020 brought a new challenge for humanity Coronavirus Disease 2019
(COVID-19). This virus has its origin in Wuhan City gradually spread throughout China and
became global health threat.12So far, COVID-19 is considered the largest Outbreak of atypical
pneumonia since severe acute respiratory illness (SARS), which occurred in 2003.3 Other than
that SARS, the total number of cases and the number of deaths from COVID-19 got much higher
after the weeks of the first outbreak.4The epidemic was first detected in December 2019 when
the number of Cases of pneumonia of unspecified etiology has been associated with
epidemiological contact with a fish market and contacts not found in Wuhan City, Hubei
Province5. In January 2020, the number of cases and death toll from COVID19 both inside and
outside Wuhan increased and spread exponentially the 34 regions of China. Hence, COVID-19 is
based on the impact the epidemic was recognized by the World Health Organization (WHO) a
global public health emergency.
COVID-19 in Pakistan
The first case of COVID-19 was in Pakistan on February 26, 2020 reported in Karachi.7
According to the National Ministry of Health Department of Regulation and Coordination of
Government Services the virus has spread steadily to other parts of the country and to Pakistan
Within days, confirmed cases of COVID-19 increased at 56.386. However, 19,142 people have
recovered and there have been 1,225 deaths from this virus.8
4
Previous studies have examined the epidemiology and clinical characteristics of infected
patients,
910
the genomic characteristics of the virus,
11
and government global health issues.12
Options are limited at this time Information on psychological impact and mental health People
during COVID-19. This information is particularly important given the ambiguity associated
with such an epidemic unmatched size.
Psychological Effect ofCOVID-19
A study examining psychological responses and factors related to the early stages of
COVID-19 in public showed moderate to severe and moderate psychological effects Symptoms
of major depression, stress, and anxiety3. Current health information and special precautions this
has been shown to be linked to a reduction in the psychological effects of Epidemic and reduced
levels of stress, anxiety and depression.
During times of epidemics, most health officials and the media mainly focus on the disease
Therefore; less attention is paid to the consequences of the epidemic mental problems. Still with
increasing mental health exposure during the COVID-19 outbreak calls for improved health
support. In China for example a guidelines for responding to mental health emergencies in
humans affected by COVID-19 were released by the National Health Commission on Jan. 27.13
These guidelines highlighted the need for multidisciplinary mental health teams to provide
mental health services to patients and Healthcare Workers (HCWs).
Effecton Health Care Workers
As the epidemic continues, it is important to equip healthcare providersystems and the
general public with the medical and psychological help they need.14 Previous studies have shown
that healthcare workers (e.g. Ambulance and other health workers) who were at high risk
5
exposure to outbreaks of infectious diseases have shown extreme stress and were emotionally
affected and traumatized. They exhibited extreme symptoms of depression and anxiety,
15
because the fear of infection is greater with the risk of exposure. There may also be a fear of
passing infection to their respectiveloved ones and families. In the majority of healthcare
workers there were conflicts and dissonances. Turns out it stems from trying to balance
professional responsibility, altruism, and personal fear for yourself and others.
Higher susceptibility to undesirable psychiatric problems was shown in HCWs working in
emergency rooms, intensive care units, and isolation rooms versus those working other
departments, probably because they are directly exposed infected patients, and their work is
more difficult.17 Likewise it has been shown that when compared to married professionals and
nurses; Individual doctors and professionals were more susceptible to psychological effects.18 A
recent systematic review of the impact of disasters on the mental health of health workers shows
a lack of social support and communication, inadequate adaptation and training risk factors for
developing psychiatric problems.17
Although isolation strategies (e.g. social distancing) are used these strategies are global to
minimize the spread of COVID-19, this method just helps protect life. Isolation can also increase
stress and is very likely to cause psychiatric problems.19 The cognitive behavioral therapy
paradigm emphasizes the need to Resilience.
20
Resilience is the ability of a person to recover
quickly. Difficulties and people who use positive emotions in difficult situations have been
shown to be resilient.21 Past literature shows this extremely resilient people encourage their
positive emotions which help it helps to deal with stress, boredom and change.21 Resilience helps
faced with mental and physical health problems, it can therefore be considered protective factor
against the appearance of psychiatric problems among them encountering difficulties.22,
6
23
similarly, a systematic review negative relationship between resilience and common mental
disorders and association of resilience with healthy behavior and quality of life.24 However,
knowledge about the factors that cushion the negative effects of perceived severity on the front
line is limited. Mental health of healthcare workers in danger. Based on risk resistance model
25
which suggests that self-control (that is, a person's ability to reversing or modifying internal
reactions and eliminating unwanted behavioral tendencies) can act as a buffer against the
negative influence of perceived severity of COVID-19 and mental health issues among the
people.
The COVID-19 epidemic has severely affected the physical, psychological and lives of
people. This has led to various psychiatric problems, such as:Panic Disorder, Anxiety, and
Depression. However, no research article has that the impact of COVID-19 on rescue workers in
Pakistan so far; a country with steadily growing confirmed cases and 27There are also reports of
health workers in Pakistan be ill equipped to deal with COVID-19.28 Hence, the main aim of this
study is to understand how emergency care workers are facing the COVID-19 pandemic and
what their stress management strategies are or possibly stress protection factors contribute to
their mental health and the challenges they face while treating COVID-19 patients. This study
will therefore provide a concrete basis for customization and execution of health intervention
measures to effectively meet this challenge and effective. It can help government agencies and
the healthcare sector Professionals in the maintenance of the mental wellbeing of HCWs in
response to the COVID-19 outbreak in Pakistan and various parts of World.
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Literature review
In their researchPouralizadeh, M., Bostani, Z., Maroufizadeh, S., Ghanbari, A.,
Khoshbakht, M., Alavi, S. A., & Ashrafi, S. (2020)29have discussed the unparalleled threat to the
health services in Iran is the pandemic of COVID-19. We intended to analyze the psychological
effect of this pandemic on nurses in the Guilan University of Medical Sciences hospitals, which
is one of the top COVID-19 outbreak provinces. 441 nurses serving in hospitals were chosen
from 7 to 12 April 2020 in a web-based cross-sectional analysis. The Generalized Anxiety
Disorder-7 and the Patient Health Questionnaire-9 were used to assess anxiety and depression,
respectively. To determine the factors related to anxiety and depression, basic and multiple
logistic regression models were used.The majority (93.4%) had contact with suspected or
confirmed cases of COVID-19 and their families were infected with COVID-19 (42%).The mean
average scores for anxiety-7 and depression were 8.64 ± 5.60 and 8.48 ± 6.19, respectively.
Anxiety was consistent with females operating at the COVID-19 allocated hospital suspected of
COVID-19 infection and inadequate personal protective equipment. Depression was strongly
associated with the presumption or evidence of COVID-19 infection and inadequate personal
protective equipment for females with chronic disease. The result notes that the risk of mental
disease is high for healthcare workers. Continuous monitoring of the psychological effects
following outbreaks of infectious diseases can be part of the health care systems' preparedness
efforts.
According to the research by Cabarkapa, S., Nadjidai, S. E., Murgier, J., & Ng, C. H.
(2020)30Frontline health care staff (HCWs) are among the most vulnerable groups at risk of
mental health issues when the nation is fighting the COVID-19 pandemic. Not well known are
the many threats to the well-being of HCWs. There is a scarcity of knowledge in the literature
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about how to better avoid psychological distress and what interventions are required to
minimizedamage to the well-being of HCWs.A systematic analysis using PRISMA methods was
used to analyze the psychological effect on HCWs confronting epidemics or pandemics, using
three electronic sources (PubMed, MEDLINE and CINAHL), dating back to 2002 until the 21st
of August 2020. The search plan included terminology for HCWs (e.g., nurse and doctor),
behavioral health (e.g., wellness and psychological), and virus diseases (e.g., disease and
pandemic) (e.g., epidemic and pandemic).Only analyses of more than 100 frontline HCWs were
included (i.e. doctors or nurses in near proximity to contaminated patients).A total of 55 studies
were included with 53 using quantitative and 2 qualitative methodologies. The validated
assessment instruments were used in 50 of the quantitative tests, while 5 used novel
questionnaires. The trials have been carried out in numerous countries and have involved persons
with SARS (13 studies), Ebola (1), MERS (3) and COVID-19 (38).Findings indicate that with
many studies suggesting an elevated risk of developing trauma or stress-related illnesses,
depression and anxiety, the psychiatric effects for HCWs are complex. At the core of the
emotional problems encountered is fear of the unknown or being tainted. It seems that being a
nurse and being female conferred greater risk. Bad effects were increased by the perceived
stigma of family members and community, primarily tension and loneliness. Among the
conflicting sociocultural environments, coping mechanisms differed and tended to vary among
doctors, nurses and other HCWs. Implemented improvements and future prevention suggestions
have continuously demonstrated the need for better psychosocial assistance and easier
distribution of information relating to the disorder.Present and potential research goals for the
preservation of health in frontline HCWs will be notified by this study. Action plans to improve
at the level of policy-makers in order to provide HCWs that play a vital role in large-scale
9
epidemic outbreaks with an expanded spectrum of resources. Psychological effects are
overwhelmingly detrimental and demand more focus, likely through the intervention of
clinicians, improved understanding and proper preparation, to be mitigated.
According to the article by Lefèvre, H., Stheneur, C., Cardin, C., Fourcade, L.,
Fourmaux, C., Tordjman, E., ...& Moro, M. R. (2020)31the 2019 coronavirus disease pandemic
poses the health care industry with unparalleled problems. The burden on health care personnel
continues to escalate, accentuated by the population's containment (lockdown) and the
extraordinary duration of this emergency. Overwork, degraded conditions of treatment because
of the never-ending emergency, and the risk of exposure to the infection, separately and
particularly together, can lead to acute psychological trauma or signs of burnout. At Cochin
Hospital in Paris, France, this initial initiative was designed to avoid these potentially drastic
psychological effects, assist medical personnel, and recognize those most affected and provide
specific treatment to them. The Port Royal Bulle (the Bubble) is a service and a place for healing
and assistance for hospital caregivers by hospital caregivers, giving these staff aid in
decompression and relaxation. It incorporates a warm and loving welcome that encourages focus,
listening, interactions, and conversations as required, empathic encouragement, and the
opportunity to partake in physical activities that are calming, stimulating, or low-impact.
Caregivers are taken care of. The Bubble is a program that is easy to set up and which seems to
satisfy the standards of practitioners. As a supplement to current services, making it permanent
and expanding its scope could continue to assist health care workers in their jobs.
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Method
Research Design
This qualitative research used the thematic methodology of the system and made an initial
attempt to examine defense mechanisms and coping mechanisms linked to COVID-19 among
emergency frontline HCWs in Pakistan. Thematic analysis is an interpretive approach in which
evidence is methodically analyzed to identify correlations within the data to provide a revealing
account of the phenomenon.32 This method aims to establish relevant concepts without theory
being clearly developed.33 This approach was used to produce a detailed and complex concept of
complex phenomena.34 In order to isolate and code all topics relevant to the study target, both
writers read data many times separately.
Participants
Frontline emergency HCWs specifically concerned with COVID-19 patients were
recruited between April 2, 2015 and 25 April 2020 via the convenience sample design.
Advertisements were posted on multiple social networking sites to attract participants. The
inclusion requirements included (1) frontline health workers who specifically targeted patients
with COVID-19 (i.e. transferred them to COVID-19 wards/centers from their homes, nearby
hospitals and other locations) and (2) volunteers that involved in the study. The exclusion criteria
did not force the participants to participate or withdraw from the analysis during the interview or
one week after the interview. Initially, 20 participants decided to be part of the study, but, for
some personal reasons, 5 of them refused. There were 15 participants in the final survey (Table
11
1) who were guaranteed of confidentiality and anonymity. The report building sessions consisted
of sharing the study's purposes with survey participants prior to interviews.
Participant
Age
Designation
Gender
Qualification
No.
Years
of
Service
P1
29
Emergency Medical Technician
Male
Higher Secondary + Diploma
5
P2
32
Emergency Medical Technician
Male
Bachelor degree
7
P3
33
Emergency Medical Technician
Male
Master’s degree
8
P4
34
Emergency Ambulance Driver
Male
Secondary
5
P5
30
Emergency Medical Technician
Male
Higher Secondary
7
P6
33
Emergency Medical Technician
Male
Higher Secondary
8
P7
35
Emergency Ambulance Driver
Male
Secondary
10
P8
33
Emergency Ambulance Driver
Male
Secondary
8
P9
29
Emergency Medical Technician
Male
Higher Secondary + Diploma
4
P10
30
Emergency Medical Technician
Male
Higher Secondary + Diploma
5
P11
30
Emergency Medical Technician
Male
Bachelor degree
4
P12
35
Emergency Medical Technician
Male
Bachelor degree + Diploma
6
P13
36
Emergency Medical Technician
Male
Higher Secondary + Diploma
12
P14
32
Emergency Medical Technician
Male
Higher Secondary
7
P15
29
Emergency Medical Technician
Male
Higher Secondary
2
Interview Outline
By looking through previous literature, discussing with qualitative research experts and
doing some pre-interviews with frontline HCWs, the outline of interview protocols was planned.
Probes for the core subject were also included in the interview protocols (i.e., how do you see
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COVID-19 in Pakistan/what is your understanding of COVID-19 in Pakistan?). The interviews
were conducted in Pakistan's national language (i.e. Urdu), in which the interviewer and
participants were both relaxed expressing their opinions. The interviews were conducted in
Pakistan's national language (i.e. Urdu), in which the interviewer and participants were both
relaxed expressing their opinions. The interviews were conducted in Pakistan's national language
(i.e. Urdu), in which the interviewer and participants were both relaxed expressing their
opinions. The interviews were conducted in Pakistan's national language (i.e. Urdu), in which the
interviewer and participants were both relaxed expressing their opinions.
Data collection
After participants read and understood the explanatory statements and signed written
informed consent, the qualitative interviews were performed. The interviewer had a PhD in
Psychology and considerable observational interview experience and had worked on a number of
qualitative research studies on resilience and protective factors in diverse societies. Furthermore,
the interviewer was a well-versed clinical psychologist with almost 10 years of evidence-based
practice, teaching, and empirical research expertise. The researcher was, thus, qualified to
perform this study.
On the basis of the ease and comfort of each interviewer, the sites for performing
interviews were selected. A comfortable atmosphere was maintained, consisting of 2 chairs and a
small table between each researcher and the interviewer. They recorded the interviews, which
were kept strictly secret. Furthermore, personal space was given to specifically listen to
participants without meddling with their space. There were limited disturbances, ample lightning
and appropriate temperature in the space where interviews were held peacefully. After 15
13
interviews, the appearance of similar responses indicated data saturation acquisition, so no
further interviews were performed. It took about one hour for each interview.
In addition, if they encountered emotional distress/discomfort during the interview,
participants were asked to interrupt the interview and take a break or avoid further interviews. In
the event of emotional distress/discomfort, a directory of therapy facilities was given that
provided free therapeutic support, but none of the participants exhibited any distress.
Participation in this research was optional and there was no responsibility on researchers. They
were able to build on the research on which it originated, during the interviews or one week after
the results had been obtained. When conducting interviews, the researchers maintained an
unbiased perspective and maintained an amiable relationship with the participants. 1 or 2 report
building sessions were held before conducting individual interviews with each participant.
Data Analysis
Transcription process started after recording interviews, and the data were subsequently
evaluated by thematic analysis methodology.
Transcription
Braun and Clarke34 have proposed separate transcription approaches based on
computational techniques. Orthographic transcription was undertaken and both verbal and
nonverbal phrases consisted of a "verbatim" account. Consequently, both the verbal and
nonverbal answers were written down. The research was carried out separately by both
journalists. Several times, they read the transcript, simplified and received substantive
statements, and the concepts and sub-themes were devised. The contradictions between both
writers were solved and a consensus was established by mutual dialogue. This procedure was
14
conducted independently of results from any prior research. Numbers were allocated to each
researcher to evaluate data as well as to preserve participant anonymity.
Ethical Review
The research was performed in compliance with the Ethical Principles of the Helsinki
Declaration of 1964 and its Later Revisions or Equivalent Ethical Standards. For the reports to be
released, written informed consent was sought from both participants and participants consented.
In addition, formal permission was received for data collection from the authorities concerned.
The authors ensure that no academic wrongdoing has occurred, such as plagiarism, distortion of
evidence, falsification, and repetitious publications.
Results
The survey consisted of 15 men between the ages of 28 and 38, with a mean age of 31.87
§ 2.82. Where the career experience varied from 2 to 12 years with the average of 6.53 § 2.44. A
high school certification was the minimum requirement for the participants. Table 1 displays the
features of the participants.
The goal of this qualitative study was to investigate the psychological effect of COVID-19 on
emergency HCWs and to consider how they handle the COVID-19 pandemic, their stress
management mechanisms or stress defense factors, and difficulties. The themes shown in Figure
1 represent the most common themes taken from the participants' answers (Fig 1).
Stress Coping Mechanisms
Limiting Media Exposure
15
Participants stated that excessive exposure to news and social media is one of the main
elements of stress. They reported that news causes fear and inaccurate sources of COVID-19related breaking news are prevalent everywhere. In addition, they advocated restricting
media/news consumption and practiced the same with their families.
Participant 3 expressed his views: "Another concern is the hysteria around coronavirus generated
by media and social media, I do not reject the seriousness of the issue, but checking social media
repeatedly aggravates anxiety and I have now restricted this exposure to get breaking news and
have asked my kids not to be distracted with news alerts, because I am not aware of the origins
of the message/news.”
Participant 5 said: "These days it is very difficult to tell the real facts from the fake news, and the
media is bombarded with both. You are advised to trust them." on established sources of
COVID-19 information. I used to scan social media news and alerts almost every hour at first,
because I've limited this visibility, I feel much better.”
Limited Sharing Of COVID-19 Duty Details
Participants have emphasized their important coping strategy by not sharing explicit
details about the duties they undertook in working with patients with COVID-19. Participants
felt that disclosing such data could raise the insecurity of their significant others and intensify
their COVID-19-related anxiety and terror.
Participant 2 shared: "In my opinion, my utmost effort to reveal the minimum information to my
family about my exact duty to deal with patients with coronavirus is beneficial in dealing with
their current stress."
16
Participant 12 shared, "If I disclose how many hours I have spent treating / transmitting
coronavirus patients, my family can get sick with fear and their stress will increase."
Participant 11 shared, “I just told my wife that I was open to working with coronavirus patients,
but not in detail, and I regret sharing because I know that it is very difficult and disturbing for
her, but she does not know any specifics about my current duty.”
Religious Coping
Religious coping is an important theme derived from the records. Considering the
evidence from Muslim participants, one of the important topics was religious coping. In order to
deal with the COVID-19 pandemic, faith-based rituals and value systems are seen to play an
integral role in the lives of the chosen sample. There are some quotes that are shared:
According to Participant 10: "My coping is based on my belief that without His will, coronavirus
is no exception, any disease/illness/virus comes from God and cannot harm us. I know I have to
take precautionary steps and I do that, but in the end, knowing that this virus is indeed a
challenge from God helps me to cope better and when I remind myself of this, I feel calm.”
Similarly, Participant 4 said, "Let's note the verses from the Holy Quran every soul can taste
death,' I think it's simply the fear of death that is connected with this pandemic and God fixes day
for death for every human according to my belief system, so I don't have much choice here and I
know I could die without this virus and even survive after being diagnosed with it, so I rest my
case here and I know I could die without this virus and even survive after being diagnosed with
it.”
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Participant 1 shared: "I think coronavirus is a vengeance from God and it is time to consult Him
for forgiveness more, this makes me sad, but recollection of God gives me strength and
confidence when doing this daunting duty and it is a coping for me to handle my own tension.”
"Fear of God is better than Fear of Corona," according to Participant 5. This is a remarkable
trend that represents the participants' strong respect for religious beliefs and religion. Since
participants use religious coping and stress their spirituality in order to cope with stressful
conditions such as pandemics, it can be inferred that faith/religion may be an aspect of resistance
for the participants chosen and acted as a defensive factor.
It Is Just another Emergency/Line Of Duty
By conceptualizing it as yet another emergency, as they are prepared for a wide variety of
emergencies, some of the participants discussed their dealing with COVID-19 associated stress.
By remembering their nature of responsibility and telling themselves that it is not the first time
they have dealt with threatening incidents, they managed to normalize their tension.
Participant 13 shared: “We are public health professionals who also have emergency medical
services, but it's nothing new to me but that we need some more precautionary precautions to
carry personal protective equipment (PPE).”
Participant12 shared: "Yes, no doubt this pandemic condition is threatening and instilling
fear by interacting specifically with coronavirus patients, but I believe it's all connected to how
you view it. I keep telling myself that it's my responsibility to provide emergency health services,
and I'm only doing the same duty I've been doing for the past decade.”
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Participant 2 shared: "It is my responsibility, if I am overwhelmed with stress how will the rest
of the people around me deal with it. I'm reminding myself and all the coronavirus patients I'm
working with that it's a transient situation that this, too, is going to happen.”
The manner in which participants neutralized/normalized the acts of conducting the
special duties of working with patients with Covid-19 and expressed their sense of duty in the
above quotations, reflects their motivation and professional mindset not only to fulfil their work
obligations, but also to serve humanity.
Altruism/Empathy
Most of the attendees expressed their willingness to represent society and their
empathetic attitude towards patients with COVID-19 was their rationale for embarking on this
career in emergency care.
Participant 7 shared his feelings: "My thoughts (while moving a diagnosed or suspected
coronavirus patient) always revolve around family members of the patient, even when I'm back
from duty. I'm an ambulance driver and 12 patients have been transferred from their homes to
quarantine centers so far. When I arrived at their place to take them, I found their family
members weeping and this indeed is a moving moment when there is doubt that whether the
patients will be returning to their family or not. I keep ruminating that my family might still do
this to me and this gives me the understanding to appeal to their situations and I strive with
dedication to perform my duties”
Participant 9 expressed his viewpoint: "I try to concentrate on the positive aspect that I
serve humanity and my job contributes to saving the lives of people."
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Participant 13 shared: "My motivation for joining this service was my love for doing something
for a greater cause, something for mankind, and I feel it is high time to play my part and
dedicatedly fulfil my duties.”
Participant 15 shared his experience: “I met with a family returning from Iran today, and
they were confirmed positive for Covid-19, including their 5-year-old daughter, and we were
told to move the infant to the children's hospital alone and to other field hospitals/quarantine
centers for the rest of the patients/family members. The kid was screaming, and she was too
scared to be alone, and this was the moment when I did not contain my emotions, and I begged
the authorities to bring the mother and child into the same quarantine camp.”
Challenges
Psychological Response
Almost every person in the world was impacted by the COVID-19 pandemic, and it was
projected to have a more serious psychological effect on frontline emergency workers. Mixed
viewpoints were expressed by the participants; some indicated exaggerated tension while coping
with COVID-19 patients, while others demonstrated flexibility and controlled their feelings
correctly as shared in the previous series of topics. Due to ambiguous circumstances, both
participants recognize fear and anxiety as common prevalent symptoms.
Participant 5 expressed his views: "Stress is evidently very prevalent in everyone, not just
the front liners, but also the public. My stress is linked to my kids, what if I take the virus home
and move to my kids, this is my biggest stress, since I take all the precautionary steps, but I still
have reservations about the consistency of the PPE delivered.”
20
Participant 1 shared: "Because I am doing quarantine center service, my appetite and
sleep cycle are interrupted.
According to Participant 6: "The four days of the last week were quite comfortable as I
did not deal with any emergency, but I have been really busy from the past few days as I am
constantly introduced to patients with coronavirus and it is overwhelming, anxiety and stress
never stops, once one is handled, next is there, and day by day this pandemic is getting
frightening.”
As Participant8 stated, "I had no emotional problem while doing these duties, but
yesterday I felt poor, I had to deal with a family diagnosed with coronavirus, it was a wealthy
family living in a posh place, they refused to be admitted to the state setup of the quarantine
center and preferred popular private center/hospital but sent their servant to the one they refused
for them. This division of class makes me furious.”
Noncompliance of Public
The non-compliance of the public with the directives provided by the government to
combat COVID-19 is another theme extracted from the results. People did not abide by the
guidelines and escalated the condition, according to participants. In the following words, the
participants shared:
Participant 6 said, "To understand the severity of the problem, people need more
awareness. Failure to demonstrate compliance is one way of saying hello to the virus."
Participant 8 shared, “If people don't stay home and follow the rules, then all of our actions are
fine and we can never monitor the occupation.
21
According to Participant 9: "It's not that I'm desperate for the future, I'm an optimistic
person and I hope and pray that the world will soon recover from this pandemic, but we cannot
win this fight." against COVID-19 that here in our country, if the public shows respect and stays
at home, there is unfortunately a lack of awareness among the masses. "
"I come from a rural village and the residents of my village are not concerned about this
pandemic because they are unaware of the severity and can move around freely. We need more
awareness campaigns specifically for rural areas." said Participant 13.
As Participant 2 stated: "Mosques are closed worldwide and even in Muslim countries,
and public congregation gatherings for Friday prayer and other prayers are prohibited, but
religious authorities/scholars are still in a state of denial here."
In addition, Participant14 shared: "Religious scholars should be interested in educating
themselves first and then educating the masses about maintaining a social gap and offering
prayers at home during this pandemic rather than ignoring the seriousness.”
Discussion
This research was undertaken to learn how patients specifically dealing with COVID-19
emergency frontline HCWs in Pakistan view their interactions and what stress management
mechanisms they are using. The results of the thematic study found that diverse coping
mechanisms were practiced and suggested by participants to cope with stress and anxiety
resulting from the COVID-19 pandemic. Participants, for example, shared that the media was a
significant cause of heightened public tension and anxiety. In addition, it was discovered that
there was no way to validate the validity of updates or news spread through diverse channels,
leading to the confusion of this pandemic. Findings from recent research have often
22
demonstrated the function of the media in exacerbating mental wellbeing conditions.
3537
Studies
have also shown the role of stressful entertainment programming among the general population
in the creation of posttraumatic psychopathology with depression. Similarly, to shield their
significant others from any pain or fear, participants have shared minimal knowledge about their
work schedules. In studies performed on patients with HIV, this selective self-disclosure to avoid
anxiety among significant others was also documented.3840
Coping methods were often widely used for religious coping, their passion to serve
society and the country. These findings resonate with recent literature on healthcare workers
regarding dedication to their career as a key incentive to continue to work.42 In harmony with
past surveys, by attributing divine significance to the COVID-19 pandemic, participants were
improving their coping.45-48In addition, 44-49 participants in the present study were able to conduct
their duties even in the middle of the COVID-19 epidemic and viewed it as another emergency,
in contrast to ignoring obligations as seen in previous research. In line with previous research,
the ability of50-52participants to react to COVID-19's ambiguous and vulnerable condition was
their beliefs in responsibility, optimistic opinions and perspectives on their positions during the
pandemic, which also affected their resistance and coping.
Similar to prior research, current study participants recognized any apprehension and
distress related to unpredictable situations.
53-54
However, endurance and cognitive control
adequately drove participants to continue operating. Participants have voiced their fears over
civic non-compliance and reported that the community's conduct was deteriorating the nation's
condition. Various pandemic reports such as Ebola and SARS have also demonstrated that
various forms of non-compliance have impeded governments and health departments' ability to
function successfully in dealing with epidemics.55, 56 One of the reasons for this non-compliance,
23
as well as denial by religious experts of the seriousness of COVID-19, may be government
mistrust. Studies have shown that people who distrust government are far less likely to cooperate
with government-directed structures designed to cope with different epidemics.57-60 In addition,
some respondents have shown a lack of knowledge of the provision of mental health resources,
especially in rural areas.
Any guidelines are proposed on the basis of these results. For example, building not only
health services, but also strong ties with the population, regaining their faith, breaking their
denial, and effectively engaging each member of the community in the battle against the
pandemic is crucial. In this, the position of community health workers is very important, as they
can bind neighborhoods and health facilities. In addition, building on the prevalent coping
mechanisms of HCWs is important. In order to gain a deeper understanding of the role of peer
networks in helping health staff, implementation analysis must be conducted. In addition,
awareness programmers modulated by government-regulated agencies are important.
Strengths
In one of the early attempts to investigate the coping strategies and difficulties of
frontline HCWs in Pakistan with respect to COVID-19, this research was performed. Most of the
prevalent qualitative experiments are retrospective, but this research was carried out in the earlier
period of the pandemic. In addition, instead of only explicitly performing interviews, a few
relationship building sessions were held with each participant to familiarize them with the
researcher and the purpose of the research. This culminated in a detailed interpretation of the
perspectives of the learners. Contrary to the results of previous research, a number of coping
24
strategies/protective factors that were buffering against the threats of the COVID-19 pandemic
were seen by the participants of the present study.
Limitations
This analysis has certain drawbacks. When the pandemic was underway, the research was
carried out and we were mindful of not removing the participants from important jobs, so
interviews were frequently paused or disrupted because certain other emergency calls and duties
had to be attended by the participants. The results lack generalizability due to the contextual
aspect of the analysis, which only discuss the experiences of emergency frontline HCWs. It will
also not expose such viewpoints, such as those of other HCWs, administrators, members of the
group, and patients. In addition, we were mindful of government-enforced social/physical
distancing rules, but focus group meetings should not be held. As a result of the exploratory
aspect of the analysis, the sample was also kept small. This research did not reveal results from
private facilities with HCWs that could have diverse pandemic backgrounds and multiple coping
strategies that require exploration. The thesis used a thematic analysis approach; therefore, the
in-depth interpretation might not be captured and only the themes examined for semantic and
latent meanings are recorded. For more linguistic interpretation of the results, a more in-depth
approach such as phenomenology or grounded theory may be used in related future studies.
Authors’ Own Reflections
Although the authors have previous expertise in conducting qualitative research and
using various methods of data collection, including semi-structured interviews, focus group
conversations and ethnographic observation, the collection of data during the pandemic was a
daunting activity, in particular maintaining social distance and all precautionary steps for the
25
participants of the study as well as reseeding. The investigators employed a research assistant
who had sufficient interviewing skills and worked in the health sector; there was no need for a
different research gatekeeper.
Conclusions
This research provided a detailed and in-depth understanding of how frontline emergency
HCWs cope with the pandemic of COVID-19, their techniques for stress management, or
defensive factors, and difficulties when Work with patients with COVID-19 using the review
thematic approach. It was found that media were mentioned during the pandemic to be a major
source of exacerbating anxiety and mass stress levels as it was not possible to assess the validity
of alerts or shared news. In addition, their endurance and coping strategies were strengthened by
moral coping, passion to serve society and nation, calling this pandemic only an emergency, as
well as optimistic opinions, and perspectives on their positions during the pandemic. The results
signal the introduction of major and sustained public awareness campaigns to promote general
population knowledge, targeting modes of transmission and situation-specific prevention
measures, as well as countering distrust, myths and misconceptions. In order to boost their selfesteem, morale, and the capacity of HCWs to adapt to the pandemic, the improvement of health
networks should be encouraged by supplying frontline HCWs with critical knowledge about
accessible mental health resources. In addition, the results act as a guideline and motivation for
future studies on resilience and the need for resilience-based approaches, preparation and
funding for emergency health workers in Pakistan and the region in mental health research. In
the wake of the COVID19 epidemic in Pakistan and different parts of the world, this may enable
government bodies and healthcare practitioners to protect the psychological well-being of the
HCWs.
26
Acknowledgments
We are grateful to the study participants for trusting us with their precious time and
engaging in the research.
27
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