How Can We Deal with Psychosocial Issues in an Emerging Infectious Disease Outbreak? Lessons from a Qualitative Study for the MERS Outbreak in Korea

Abstract

Background

The 2015 Middle East respiratory syndrome (MERS) coronavirus outbreak in Korea led to profound emotional and social burdens, especially in patients and health care professionals.

Materials and Methods

Focus group interviews were conducted with 2 patients, 1 family member and 6 health care professionals about psychological distress related to MERS in 2017 and analyzed the interview data using the consensual qualitative research method.

Results

Four domains and 17 core ideas were identified within three interview groups, including psychological distress during the outbreak, problems regarding the response to the outbreak, positive experiences, and future directions for enhancing intervention to improve mental health and prevent psychosocial problems during the outbreak. Psychological consequences were affected by the characteristics of the emerging infectious disease and the structure and process of institutional or governmental response to the MERS outbreak. Mental health services and psychosocial support reduced the negative impact on psychological distress.

Conclusion

The MERS outbreak in 2015 gave rise to emotional and social injuries to patients and health care professionals, some of which can be long-lasting constraints in their lives. Preparedness in a society’s response to a pandemic considering mental health in related parties can minimize negative psychological consequences and enhance resilience at the individual and society levels.

Graphical Abstract

Introduction

The Middle East respiratory syndrome (MERS) outbreak in Korea in 2015 was one of the biggest health crises related to infectious diseases in the country [1]. MERS first appeared in Saudi Arabia in 2012 as a novel coronavirus infection that spreads mainly via respiratory systems [2]. In Korea, once the first case was reported in May 2015, the number of people infected with MERS increased rapidly [3]. In total, 186 people contracted MERS with 38 deaths (20.4%) and 16,693 people were quarantined in two months [4]. Until the situation ended eight months later, many people suffered from psychosocial problems as a result of the outbreak of this infectious disease [5,6]. Approximately 90% of Korean citizens were concerned about infection, and more than 40% of patients with MERS complained of symptoms of anxiety [7]. Many medical staff also worried about infection when caring for infected patients [8].

In addition, people may experience different psychosocial difficulties depending on their situation during an infectious disease outbreak. These range from the experience of the isolation and the stigma attached to the sickness [9] and those quarantined [10], to professionals’ moral conflict between worry about infection and their duty of care [11]. Although these difficulties are mainly attributed to the characteristics of infectious diseases, psychosocial difficulties could be reshaped depending on how a society responds to an outbreak of infectious disease [12,13]. This societal response includes whether correct information is delivered or support is offered for the quarantined and medical staff. Therefore, to grasp the overall psychosocial issues related to a pandemic, it is insufficient to only investigate the psychiatric problems of patients with an infectious disease. The overall social response to an epidemic should consider measures to protect mental health according to the experiences of various affected parties, including patients, their families, and staff working in hospitals and communities.

Therefore, this study aimed to explore the psychosocial difficulties experienced by different affected parties during the 2015 MERS outbreak in Korea and seek answers for ways of effectively responding to infectious diseases in the future. Previous studies primarily used quantitative methods to measure mental symptoms such as depression and anxiety [14,15,16]. Therefore, this study directly explored the experiences and perspectives of patients and health care providers who were closely involved in the 2015 MERS outbreak to understand psychological distress in the context of social responses.

Materials and Methods

1. Participants

We assumed that individuals’ perspectives might vary, depending on the experience or role played, and wanted to include as many roles as possible concerning the MERS outbreak. The inclusion criteria for participation in the study were as follows: (1) those aged 19 years or older who voluntarily agreed to participate in this study, (2) those who had contracted MERS, or their family had, or (3) those who had carried out MERS-related work in hospitals and communities in 2015 in Korea. Participants were recruited from May to July 2017. MERS survivors and their relatives were recruited from the ongoing MERS cohort study, and health care professionals were recruited through purposive and snowball sampling.

After recruitment, the participants were divided into three groups. Group 1 consisted of MERS survivors and their family caregivers, Group 2 consisted of health care professionals and a medical ethicist working at a hospital (Table 1). Group 3 consisted of health care providers from a community and mental health center. Each group consisted of three participants and one research team member.

Table 1. Participants characteristics.

Variable			Frequency (N = 9)
Gender (M/F)			3/6
Age (years)
	20 - 29		1
	30 - 39		1
	40 - 49		3
	50 - 59		2
	60 - 69		2
Type of experiences or roles during the 2015 MERS outbreak
	1) Group 1: Survivors and their family
		- MERS survivors	2
		- A MERS survivor’s family member	1
	2) Group 2: Healthcare professionals working at a hospital
		- An internal medicine doctor of the infectious disease division who cared for patients with MERS at an isolated ward	1
		- A nurse who cared for patients with MERS at an isolated ward	1
		- A medical ethicist who participated in research, especially regarding the ethical issues associated with the MERS outbreak and ethics consultation in a hospital	1
	3) Group 3: Healthcare providers in a community and mental health center
		- A doctor at a community health center who supported patients with MERS and quarantined individuals	1
		- A doctor at a mental health service center who supported patients with MERS and quarantined individuals	1
		- A nurse at a mental health service center who supported patients with MERS and quarantined individuals	1

M, male; F, female; MERS, Middle East respiratory syndrome.

2. Ethics statement

This study protocol was reviewed and approved by the Institutional Review Board of the National Medical Center (IRB No. H-1505–054–002). Informed consent was obtained from all participants when they were enrolled in the study. All participants were informed that they could withdraw from the study at any time.

3. Data collection

Each group was interviewed separately in August 2017 at a general hospital in Seoul. Before the interview, the purpose and method of the study were explained to all participants, as well as that the interviews would be recorded to obtain a transcript of the data, and the participants signed the agreement.

Three research team members each interviewed one of the three groups, using four semi-structured, open questions: (1) Did you experience any psychosocial difficulties during the MERS outbreak? (2) What do you think of the government’s response to the MERS outbreak in terms of psychological and mental health care? (3) What support for mental health care was needed? (4) What do you think we should consider when preparing mental-health support for infectious disease outbreaks in the future?

Each interview took between 60 - 90 minutes. All interviews were recorded and transcribed.

4. Data analysis

Consistent with guidelines for Consensual Qualitative Research by Hill [17], all analytical decisions were made by consensus. First, research team members read all transcribed interviews independently, and generated a list of potential themes and domains. After, they met and created a combined list of domains by discussing each member’s list. Next, each reviewer independently coded the first group’s interviews. The research team reviewed each coding to ensure consistency across members. After completing the initial coding, the research team conducted a cross-analysis by constructing common themes across interview groups, which led to the development of a "category," which explains the content of each domain. Similar to the domain coding process, the dyads of team members coded until a consensus was reached. The fully coded data were sent back to an auditor and auditor’s feedback was integrated into the final domains and categories.

After the cross-analysis process was reviewed by the auditor, core ideas were categorized using frequency labels: “general” was applied to ideas mentioned by 8 - 9 of the 9 respondents, “typical” was applied to ideas mentioned by 5 - 7 respondents (i.e., at least 50% but less than 90%), “variant” was applied to ideas mentioned by 2 - 4 respondents (i.e., at least 20% but less than 50%), and findings applying to single cases were placed in a miscellaneous category and not included in the results.

Results

Through data analysis, 17 core ideas were derived from four domains: (1) psychosocial issues related to the MERS outbreak, (2) problems in responding to the MERS outbreak in terms of psychosocial aspects, (3) positive experiences, and (4) future directions for emerging infectious diseases in terms of psychosocial aspects (Table 2). Seven of the 17 experiences and perceptions were common across the three groups. Most similarities were identified in the suggestions for the future direction of the response to new infectious diseases. Groups 2 and 3 had similar core ideas, confirming that healthcare providers shared common perceptions and experiences.

Table 2. Main findings from focus group interviews in three groups.

Domains	Core ideas	Total	Group 1a	Group 2b	Group 3c
1. Psychosocial issues related to the MERS outbreak	1) Worries relating to families	Typical (7)	Typical (2)	Typical (2)	General (3)
	2) Sense of isolation	Typical (6)	Typical (2)	Typical (2)	Typical (2)
	3) Work-related conflicts and demoralization	Typical (5)	0	Typical (2)	General (3)
	4) Long-lasting aftereffects	Variant (4)	General (3)	Variant (1)	0
	5) Anxiety about infection and climate of fear	Variant (4)	0	Typical (2)	Typical (2)
	6) Responsibility and burden for patients	Variant (2)	0	Variant (1)	Variant (1)
2. Problems in responding to the MERS outbreak in terms of psychosocial aspects	1) Failure in the initial response to the outbreak	Typical (6)	Typical (2)	Typical (2)	Typical (2)
	2) Inadequate management of the quarantined	Typical (6)	Variant (1)	Typical (2)	General (3)
	3) Uncertainty of information and misperception	Typical (6)	0	General (3)	General (3)
	4) Difficulties in collaboration between the government and medical institutions, between the central government and the local government, and within hospitals	Typical (5)	0	Typical (2)	General (3)
	5) Unprepared personnel	Variant (2)	0	Variant (1)	Variant (1)
3. Positive experiences	1) Mental health support	Variant (4)	0	Typical (2)	Typical (2)
	2) Support from the community	Variant (3)	0	0	General (3)
4. Future directions for emerging infectious diseases in terms of psychosocial aspects	1) Mental health support system (target-based approach, standardization, and the role of local governments)	General (8)	Typical (2)	General (3)	General (3)
	2) Accurate information	Typical (7)	Typical (2)	General (3)	Typical (2)
	3) Establishment of a response system to an emerging infectious disease	Typical (5)	Variant (1)	Variant (1)	General (3)
	4) Support for survivors and medical staff	Variant (4)	General (3)	Variant (1)	0

^aSurvivors, and their family.

^bHealthcare professionals working at a hospital.

^cHealthcare providers in a community and mental health center.

MERS, Middle East respiratory syndrome.

1. Psychosocial issues related to the MERS outbreak

All three groups reported worries related to their families and a sense of isolation. Group 1 highlighted the mental and social aftereffects of the MERS outbreak, whereas Groups 2 and 3 focused on work-related conflicts, low morale, and fear of infection during their job.

1) Worries relating to families (Groups 1, 2, and 3)

Most participants reported worrying that they might infect their relatives. Families of health care providers (Groups 2 and 3), who took care of the sick, also experienced discrimination because of their relationship with the healthcare providers. Patients suffered from feelings of guilt, as their families were unable to do important things, such as a college entrance exam, due to their isolation.

“We were stressed out, but we had a sense of mission. I think it was our family members who were more stressed out. One of my colleagues had a little child, and the daycare center did not allow the child to attend. There was no [scientific] evidence, but people excluded the family members.” (Group 3)

2) Sense of isolation (Groups 1, 2, and 3)

Patients and their family caregivers were isolated from society while the patients were receiving treatment for MERS (Group 1). This caused the patients and family caregivers to experience loneliness and extreme isolation, to the extent that some participants reported having experienced paranoid or suicidal ideas. Groups 2 and 3 also reported that their patients experienced isolation and discrimination.

“It was so frustrating. I had no idea what was going on outside, and I could not see my family. I was completely isolated from the world. You never understand until you experience it.”; “It was worse than being in prison. After I regained consciousness, I felt like killing myself because everything was unbearable.” (Group 1)

Even after complete recovery, the participants experienced being left out or threatened by their neighbors and colleagues.

“People look at me with strange eyes when I say I contracted MERS. It is like we are treated as if we are leprosy patients from the 1950s and 60s.” (Group 1)

“People put post-it notes on a patient’s mailbox with rude remarks and curses, like ‘Move’ and ‘Leave this town.’” (Group 3)

3) Work-related conflicts and demoralization (Groups 2 and 3)

Medical staff suffered from overload because the staff in other departments were unwilling to support them and only a limited number of people could be exposed to the risk of infection. This overload led them to feel a sense of deprivation. Healthcare professionals who worked in the community during the MERS outbreak faced criticism and consequently, experienced demoralization.

“Because more patients came with more severe conditions, we couldn’t handle it, but people in other departments did not want to help us. It was a bit hard to persuade them, and we were hurt a lot while we tried to ask for help.” (Group 1)

“Conflicts occurred even among doctors. Some physicians did their best, taking risks, but others tried to get away from the situation. Even one physician, who was not married, said, ‘I will quit because I am afraid I will not be able to get married.” (Group 3)

“While I worked at a call center for support during the MERS outbreak, I was frequently abused by the callers. I could not find any sense of pride in my job. My spirits dropped. We were the ones who were working on the front line, but we could not receive any support.” (Group 3)

4) Long-lasting aftereffects: mental symptoms, avoidance, economic difficulties, and alienation (Groups 1 and 2)

After the MERS outbreak ended, the difficulties faced by patients and health care providers continued. Patients experience various aftereffects, ranging from physical symptoms (e.g., coughing) to mental symptoms (e.g., insomnia, anxiety, and depression). Survivors reported that they avoided places or things that reminded them of their experience of MERS. Some medical staff members also received psychiatric treatment due to their painful memories. Some participants had to quit their jobs and were shunned by neighbors and friends because they were considered to be infectious.

“The suffering that patients and their families experienced is unutterable because both the physical pain and mental suffering are still going on.”

“A MERS patient is stigmatized like having a scarlet letter on your chest.” (Group 1)

“One of my colleagues, who had taken care of MERS patients, said that she wants to forget about it, but she can’t.” (Group 2)

5) Anxiety about infection and climate of fear (Groups 2 and 3)

Health care providers commonly experienced anxiety about infection because they inevitably came into close contact with the sick and quarantined. Participants regarded concerns about infection as a critical factor that made health care practitioners avoid being responsible for the sick and quarantined.

“We could not help but contact the sick without protective equipment due to emergencies. All the protocols we trained were useless. We got very scared. ‘Am I okay? I did not even check if I wore the protective equipment properly and just entered the room and did cardiopulmonary resuscitation in blood-spattered surroundings. Will it be okay?’” (Group 2)

6) Responsibility and burden for patients (Groups 2 and 3)

Because MERS is an emerging infectious disease (EID), health care practitioners took care of patients with scarce information about its course and treatment. There were no official guidelines in the early period of the outbreak, which made the situation more difficult.

“We had no idea of how much we tried. There was not enough data regarding treatments. We had to administer the treatment with little evidence. (Group 2)

2. Problems in responding to the MERS outbreak in terms of psychosocial aspects

Groups 2 and 3 frequently raised this category concerning mental and social aspects. Group 1 addressed this category only in terms of initial response and policy on the quarantined.

1) Failure in the initial response to the outbreak (Groups 1, 2, and 3)

In the early period of the MERS outbreak, there was confusion in information sharing, work divisions among government agencies, and control for MERS in hospitals. This caused people to feel more anxious and hampered health care practitioners from working efficiently.

“The superiors just made guidelines and instructions and issued them, saying ‘Do this, do that’ There were many processes, and everything was delayed. The central tower could not follow what was happening on the front line, and many errors occurred in the meantime. All of these errors and delays negatively affected citizens.” (Group 3)

2) Inadequate management of the quarantined (Pre-notices, information sharing, management) (Groups 1, 2, and 3)

In the early period of the outbreak, many people were quarantined without being given proper explanations, and the sick were transferred to hospitals without systematic information sharing. This caused both patients and medical staff to experience considerable difficulties in processing hospitalizations.

“I got a notification on a newly infected person, but there was not even a test result. Naturally, the person refused to open their door without any test results. I called the security department, and there was no guideline or procedure. It was like, ‘You are positive, and you must come with us and be isolated right now.’” (Group 3)

“You can’t get any information about when you got exposed and so on. Patients were isolated with fear, and we were the ones who first met them there. They expressed their anger and anxiety to us. I could understand them. It was like a movie: people in space suits bring you in and keep you from leaving. You get scared but do not have any information.” (Group 2)

In this urgent situation, those who were subjected to quarantine were confined in their homes without a proper explanation of isolation and “treated as a piece of luggage.” (Group 3)

3) Uncertainty of information and misperception (Groups 2 and 3)

Both the public and health care professionals did not receive accurate information regarding MERS. Misinformation about MERS also spread, and survivors were still treated as infectious patients even after the end of the outbreak.

“The most important thing is that they failed to relieve people’s anxiety. The medical professionals also did not get any information or guidelines from the government, and we all were anxious.” (Group 2)

Participants noted the media’s responsibility for the spread of misinformation. The mass media reported unconfirmed information that further hurt the sick and evoked fear among citizens. Moreover, health care practitioners’ competition in coverage prevented them from concentrating on their work.

“There were a lot of unconfirmed reports on the so-called super spreaders. The mass media published provocative articles and spread vicious rumors. It really hurts the said person, and the public is scared. It was dealt with as if it were gossip. That was a big problem.” (Group 3)

“A broadcaster reported that a patient died when she was taking care of her. We got a lot of calls that day.” (Group 2)

4) Difficulties in collaboration between the government and medical institutions, between the central government and the local government, and within hospitals (Groups 2 and 3)

Participants reported that they experienced difficulties in performing their work because the central government, local governments, medical institutions, and departments in hospitals failed to cooperate regarding the allocation of MERS patients, administration and notification of the tests, isolation management, and work divisions.

“It was the Seoul Metropolitan Government and the Korea Disease Control and Prevention Agency (KDCA) that were in charge of tests, but they didn’t care about us. They simply cared about their own schedule. The test schedule was delayed, and we conveyed this delay to the patients, who got very upset. They became very violent towards us.” (Group 2)

5) Unprepared personnel (Groups 2 and 3)

Personnel were not prepared for responding to the EID, and this unpreparedness caused an overload. Medical staff also lacked training in responding to the outbreak.

“Basically, this work was not rocket science. Anyone can do the job if they are trained just a little [but no one was willing to join us]. I understand that the least number of workers should contact the sickness, but I was like, ‘Why am I doing this alone?’” (Group 2)

3. Positive experiences

Only Groups 2 and 3 reported positive experiences. In particular, participants in Group 3, who were in charge of community care, frequently mentioned this category.

1) Mental health support (Groups 2 and 3)

Some hospitals provided support for screening and intervention and help-seeking for medical staff. Some local governments provided psychological support for all isolated people. Although some people did not understand the necessity of psychological support, most participants in our study regarded it as a positive experience.

“Many people expressed a lot of rejection. I heard heavy criticism from them, such as ‘Why would you want to know about my mental health?’ …I called all of those who had been isolated and then provided psychological support for them if I could see them in person. We also identified a high-risk group and provided financial support for them. We connected them to community health care providers. I thought that what I did really helped them.” (Group 3)

2) Support from the community (Groups 2 and 3)

Participants believed that support from neighbors, such as teachers, was substantially helpful. Some participants reported that a fear climate pervaded some regions where large numbers of people were isolated. Nevertheless, the collaborative efforts of the local government, local media, and non-governmental organizations made the atmosphere encouraging.

“I was very worried about the [isolated] children, but the teacher was very supportive. She talked with the parents regarding how to explain this outbreak and isolation to the children in the school. This family’s quarantine was known to their neighbors, but the teacher and neighbors were very supportive.” (Group 3)

“We held a ‘healing concert’. The head of the district office and the local media cooperated with us in that way. It was like, ‘We did a good job, everyone’. In the end, patients, medical staff, and government officials gathered and held a concert, which was very moving. We hung banners saying ‘Thank you’ all over this area. I think the collaborative effort in an area is necessary.” (Group 3)

4. Future directions for emerging infectious diseases in terms of psychosocial aspects

Most commonalities amongst the groups were found in this category. Support and compensation for patients were mentioned in Group 1 with high frequency.

1) Mental health support system (target-based approach, standardization, and the role of local governments) (Groups 1, 2, and 3)

All three groups noted the need for mental health support and a proactive approach.

“I think it would have been very helpful in overcoming the disease if psychiatrists had asked me regularly ‘What is the hardest for you now?’” (Group 1)

“Mental health support like this is needed. Professionals visit you and ask after you, and you answer, ‘I think I am exhausted now.’ Then, your hospital changes your work.” (Group 2)

Specifically, seamless collaboration, standardized responses for the isolated, and the role of local communities were discussed. Some participants suggested positive resources for medical practitioners and the isolated, such as collective gratitude expressions. “Psychological support should be tailored depending on its target.” (Group 3)

2) Accurate information (Groups 1, 2, and 3)

Participants stated that accurate information about new infectious diseases is needed not only during outbreaks but also after the end of outbreaks.

“That’s why I think promotions — that you are free from infectivity — would be needed once patients are fully recovered so that society doesn’t treat survivors as criminals and infectious persons.” (Group 1)

“Public education on what we should do when an infectious disease emerges is necessary. People will have less psychological trauma through education.” (Group 3)

3) Establishment of a response system to an emerging infectious disease (Groups 1, 2, and 3)

Participants in Groups 2 and 3 stated that the government should organize a system of responding to EIDs. Specifically, they highlighted the issues of consistent decision-making, work divisions between the central and local governments, and transparent information sharing.

“I think we must educate the superiors who establish the strategies so that they don’t be afraid and then educate the public, like from the top to the bottom.” (Group 2)

“I think the policymaking should be unified. For example, we are doing this in the local, and the central suddenly starts the same thing. This is confusing because there are many decision-makers. The control tower’s work should be agreed upon.” (Group 3)

4) Support for survivors and medical staff (Groups 1, 2, and 3)

The patient group discussed measures such as patient compensation and support for the physical and mental problems that they experienced.

“I want compensation for the survivors as the priority. I want the government to treat us like the survivors of the ‘humidifier scandal’. “We are in an economic hardship after the MERS outbreak.”, “I need financial support for treatment. We suffer from mental suffering as well as physical pain. It would be good if the government helped us receive psychiatric treatment.” (Group 1)

Participants in Groups 2 and 3 said that healthcare practitioners should receive compensation commensurate with their responsibility and duty so that they can be actively involved in a similar outbreak.

“Medical practitioners should be rewarded—either financially or anything—such as support for psychological care. You cannot just throw all the responsibilities and the sense of duty to them. If so, health care practitioners will be willing to volunteer for EID care. They can feel, ‘Okay, I can put up with it.’” (Group 2)

Discussion

This study confirmed that MERS survivors and health care professionals working in hospitals and local communities experienced various kinds of psychological difficulties during the MERS outbreak. The problems they experienced may be attributed to the characteristics of an outbreak of a new infectious disease, including both positive and negative contributing factors (Fig. 1).

Figure 1. Suggested framework of psychosocial issues in MERS.

MERS, Middle East respiratory syndrome.

MERS is a life-threatening infectious disease with a fatality rate of more than 20% in Korea in 2015 [3]. The characteristics of this new infectious disease outbreak include the possibility of transmission to others, a lack of information about infectious agents and disease treatment, and a rapid increase in infection. Due to these characteristics, MERS is distinguished from other well-known infectious diseases or other disasters regarding its psychosocial impact on infected patients and medical staffs. This study shows that patients stayed in an isolated environment while receiving treatment because of the “transmissibility” of the disease. These patients often worried about transmitting the disease to their families. Patients who had lost their family members during the MERS outbreak were more likely to experience feelings of guilt, which made the mourning process more difficult.

Avoiding and stigmatizing an infected person was another major challenge faced by patients with MERS. In particular, the issue of stigma may become serious in EID cases because the public fear of the disease is amplified with insufficient information and a rapidly increasing number of cases. Previous studies have also shown that people tend to worry more about EIDs than other diseases with more serious mortality rates, such as tuberculosis and malaria [18]. These findings indicate that EIDs not only cause physical injury but also emotional and social injury. This study also found that social avoidance of MERS survivors continued after discharge because of the false belief that they could infect MERS to other people even after full recovery and some of them had left their jobs or moved to other towns. As in studies on severe acute respiratory syndrome (SARS)-related stigma [19], this study also demonstrates that social stigma regarding MERS may remain long after the end of the outbreak.

Hospitals and community medical staff who cared for patients were uniquely affected by MERS. They did not feel safe because they thought they might be infected or might infect their family members. Particularly, in emergency situations such as administering cardiopulmonary resuscitation, health care practitioners could not follow the protocol to protect themselves from infection (Group 2). On the other hand, they felt difficulties in making decisions regarding treatment with little knowledge of the disease and felt more pressure when caring for MERS patients. This study revealed that the medical staff also experienced discrimination against their families, despite being a key resource in overcoming infectious diseases [5]. This caused demoralization in the medical community. Public fear caused healthcare practitioners to avoid MERS-related work. In many respects, this study revealed that the medical staff worked in extremely vulnerable psychosocial conditions and confirmed the conclusions of other studies that medical staff experienced psychological distress even when the outbreak ended [11,20,21,22].

We divided the problems in response to the MERS outbreak into “structure,” “process,” and “outcome,” according to a framework proposed by Meredith et al. [12]. We framed the resources, technologies, and allocation for a successful plan as a structure, the organized actions at individual and collective levels as processes, and the psychological difficulties that patients and the medical staff experienced as an outcome.

Regarding a structure, we identified the absence of an effective response system to the MERS outbreak in Korea, 2015. Through the SARS outbreak in 2009, the Korean government recognized the need for an organization to respond to infectious diseases and launched the KDCA [23]. However, participants recognized that the preparedness in this system was insufficient in dealing with the MERS outbreak, especially in the early period. The prompt initial response of the public health authorities to the outbreak was critical to share information, such as the routes of infected people, manage patients and the quarantined safely, and conduct preventive measures to minimize transmission of infection [24,25]. Furthermore, failure in the initial response to the outbreak led to additional failures in managing public fear and building public trust in officials [26], influencing the anxiety of and discrimination against patients and the morale of medical staff [6].

Various organizations at multi-level should be involved in responding to the epidemic of infectious diseases: the hospital, community, and government [27,28]. The study showed that the central government, local governments, community health care centers, and hospitals failed to divide the work well during the MERS outbreak. As a result, decisions were often reversed, test notifications were suddenly delayed, or the quarantined received multiple calls from different departments and ministries a day. These confusions caused anxiety and psychological distress to patients and healthcare professionals.

Next, the preparation of medical personnel should be considered because a well-trained medical staff is an essential resource in an outbreak [20]. However, this study demonstrated that medical personnel were not fully prepared in advance in Korea. This problem was intimately related to the mental health of the medical staff because education and training were important contributors to reducing the anxiety and care burdens of medical practitioners. For example, education allowed medical staff to feel ready for the SARS outbreak and work with a sense of self-efficacy during the outbreak [21].

Regarding the process, management of the quarantined was a significant issue. The ill-prepared and hasty quarantine management worsened the feeling of isolation and stigma of the disease in this study. The process of quarantine began without proper explanation or notice, and in some cases, the quarantined were not even provided medication or basic care, such as meals and menstruation measures (Group 1). The identities of quarantined individuals were, in some cases, exposed, and they experienced surveillance and avoidance by their neighbors (Group 3). Patients felt that they were transported to hospitals “like a piece of luggage” and that the environment of an isolation unit for patients was “worse than prison.” Patients also experienced distrust or even suicidal ideas, and this became another burden for the medical staff who took care of them (Groups 1, 2, 3). Being quarantined restricts profoundly individual freedom for the benefit of the community in special circumstances. Therefore, it is the reciprocal responsibility of society to ensure the physical, psychological, and social well-being of those who are quarantined and that they do not experience discrimination [29]. Consistent procedures, privacy protection and support for the quarantined and isolated patients can enhance trust in a society and prevent psychological trauma and stigma [30].

Finally, communication failure among public authority was another issue of the process. During an EID outbreak, the sharing of information and communicating risks with the public is crucial to reducing anxiety and ensuring public trust in the infectious disease response system [31,32]. In the early period of the MERS outbreak, the content and form of information disclosure from the government failed to be consistent, which caused people to distrust and fear the public system. The participants reported the negative impact of the media as well; overheated competition for coverage obstructed the medical staff’s work (Group 2), and sensational reporting based on inaccurate and unconfirmed information violated individual privacy the patient, and the quarantined as well as affected the social stigma of survivors (Groups 2 and 3).

Some positive factors derived from the interview data offer some clues to alleviate the psychosocial difficulties caused by the MERS outbreak. The cases of phone calls from supportive schoolteachers and communities succeeding in changing the atmosphere from anxious to encouraging, empowering, and grateful suggest that collective support from a community is crucial to overcoming an EID outbreak. In addition, mental health care services that were conducted in some hospitals and communities were useful in identifying high-risk group to provide financial support for the treatment and management of each case.

Mental health care support was addressed by all groups as necessary for future responses. Specifically, participants suggested a “targeted approach,” “standardization of psychosocial intervention,” and “the role of local governments.” Different approaches can be adopted depending on the severity of mental health [33]. For instance, for those with minor symptoms or health care professionals, measures to strengthen positive resources and enhance their resilience can be considered. For those who experience severe symptoms, long-term isolation, and family deaths, proactive mental health care services can be provided.

Support for patients and medical staff should be considered in future responses to a pandemic. Survivors still suffered from physical symptoms as well as secondary difficulties requiring financial and medical support. Medical professionals are responsible for caring for patients at the expense of their lives and obligations to their families. Society must make efforts to ensure patients’ physical and mental well-being, safety without stigma and discrimination, and communal recognition and reward for medical practitioners based on reciprocal responsibility [34].

The sample size of this study was too small, limiting the generalizability of the results, and there may have been selection bias. However, the purpose of this study was to explore the detailed characteristics and formation process of psychosocial difficulties through the experience of survivors and medical staff who experienced the MERS outbreak. The limitations of this study can be overcome with a large-scale quantitative research project. Furthermore, given that the study was conducted two years after the outbreak, recall bias should be considered when interpreting the data.

In conclusion, this study confirmed that MERS affected the mental health of not only patients but also health care providers. In addition, this study demonstrated that the psychosocial impacts of an EID can be attributed to the ways in which a society deals with an infectious disease as well as the characteristics of the disease. The value of minimizing psychosocial damage and maximizing individual and collective resilience in crisis is evident when we establish and enact response strategies effectively.