Quarantine experience of healthcare workers in close contact with COVID-19 patients in China: a qualitative study

Abstract

Background

This study investigated the experiences of front-line healthcare workers who had been in close contact with COVID-19 patients and had been quarantined in order to provide guidance on quarantine measures with more humanistic care when dealing with future public health emergencies.

Methods

We conducted a qualitative study using semistructured, qualitative, in-depth interviews between April and June 2022. The interviews were recorded and transcribed, followed by a thematic analysis. The study followed the Standards for Reporting Qualitative Research.

Results

This study identified the following four themes: (1) personal psychological changes, (2) increased reflection on life and work during quarantine, (3) the important role of others’ support and (4) different types of demands during quarantine and isolation. Each theme is supported by several subthemes that further illustrate the participants’ experiences.

Conclusions

Quarantine of close contacts is necessary to prevent outbreaks. Front-line doctors and nurses are at a greater risk of COVID-19 infection than others. The results showed the psychological reactions of ordinary close contacts, and the unique feelings and experiences of doctors and nurses during the epidemic. Therefore, future research should cooperate with multiple departments to assess their needs, provide them with individualised care and love and give them incentives in order to reduce their psychological burden, improve their quality of life and allow them to engage in healthcare with a healthy mind.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Healthcare workers (HCWs) who are quarantined because of close contact are often overlooked.

• An interpretative phenomenological epistemology was used to interview and explore the experiences of front-line HCWs who were in close contact with COVID-19 patients and were isolated.

• Due to the epidemic, only video calls could be used, and participants’ body movements could not be observed.

Introduction

The Omicron variant of SARS-CoV-2 was first identified in South Africa on 23 November 2021. Its high transmissibility and immune-escape properties enable it to rapidly replace previous viruses, with an effective reproduction rate three times that of the Delta variant.¹ Omicron poses a significant global risk and could lead to a spike in infections, according to a report from the WHO dated on 29 November 2021.² In March 2022, an outbreak occurred in Shanghai. According to a gene-sequencing analysis conducted by the Shanghai Centre for Disease Control and Prevention (Shanghai CDC), the patients in this outbreak—the largest in mainland China since the first wave—were infected with the Omicron variant. In total, 626 000 cases of COVID-19 have been reported by the end of May, affecting 99.5% of Shanghai’s streets.³

In particular, healthcare workers (HCWs) are at high risk of COVID-19 because of their close contact with infected patients.⁴ In 2019, when COVID-19 was spreading rapidly across China, 3387 HCWs were infected.⁵ During the COVID-19 pandemic, HCWs exhibited a high proportion of pre-existing mental health disorders, which seriously affected their quality of life.^6–8 Research shows that the prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) in HCWs during the COVID-19 pandemic was 21.7%, 22.1% and 21.5%, respectively.⁹ HCWs at all levels have been prone to high levels of burnout during the COVID-19 pandemic.¹⁰ Havervall et al’s study of symptoms and impairment, which was conducted 8 months after mild COVID-19 infection in HCWs, found various long-term symptoms that can disrupt work, social and family life.¹¹ Poorer mental health was associated with greater health fears, job stressors, perceived social stigma/avoidance and workplace safety concerns.¹² Therefore, COVID-19 infection not only impacts HCWs’ mental health, but also their long-term quality of life. Early implementation of quarantine is crucial for slowing the spread of new pathogens. Early quarantine and isolation of HCWs in close contact with COVID-19 patients is essential for preventing the spread of the virus.

The Shanghai CDC defines close contacts of COVID-19 patients as those who have had close contact with suspected or confirmed COVID-19 cases, but have not taken effective protective measures, or who have been exposed to potentially contaminated environments, either 4 days before the onset of symptoms or 4 days before the sampling of specimens from asymptomatic infected cases.¹³ At that time, China’s quarantine policy required all close contacts to be quarantined for 7 days. During the process, they were subjected to three nucleic acid tests, all of which needed to be negative in order for them to be released from quarantine. Many scholars have examined patients’ experiences,¹⁴ for close contacts—especially HCWs who have been exposed to high risk of infection. However, few scholars have examined HCWs’ experiences during quarantine. Therefore, we conducted a qualitative and descriptive study to explore the experiences of close contacts among HCWs during quarantine. Furthermore, this study can assist managers of government agencies and medical institutions in improving their responses or experiences in preventing COVID-19, focusing on the physical and mental health of close contacts and providing more humane isolation measures in response to public health emergencies.

Materials and methods

Aim

This study investigates the experiences of front-line HCW during quarantine.

Study design and settings

This qualitative study used an interpretative phenomenological analysis (IPA) approach, which involves a detailed examination of the participant’s life-world. It explored their personal experiences, focusing on individuals’ personal perception or account of an object or event instead of producing an objective statement about it. The main currency of an IPA study is the meanings that particular experiences, events and states hold for the participants.¹⁵ Using semistructured interviews, we ascertained the real feelings and experiences of front-line HCWs who were quarantined due to close contact. Front-line HCWs are those who work directly with patients in medical and health services. They are the likely to be exposed and infected with the virus. From 20 April to 18 June 2022, participants were recruited via purposive sampling from the list of close contacts of front-line HCWs collected by the Infection Management Department of Shanghai Children’s Medical Centre Hospital. The Shanghai Children’s Medical Centre is a joint project of the Shanghai Municipal People’s Government and the World Health Foundation (Project HOPE). The hospital is located in the Pudong New Area of Shanghai. It is a third-grade class A specialised children’s hospital integrating medical treatment, scientific research and teaching. The Standards for Reporting Qualitative Research¹⁶ was used in this paper (see online supplemental appendix A).

Participants

The sample size for this study was determined using theme saturation. The inclusion criteria for front-line HCWs were as follows: (1) close contacts with Omicron patients as determined by the Shanghai CDC; (2) individuals with a nursing practice certificate or a physician’s certificate; (3) individuals who volunteered to participate in the study. The researchers developed the following exclusion criteria through observation: (1) HCWs with serious physical and mental illness and (2) those who were unable to communicate effectively.

Interview procedure

Before the interviews, we sent electronic informed consent forms to the participants. Interviews were conducted with their consent. To conduct a semistructured, one-to-one and in-depth interview, we scheduled appointments with the participants in advance and selected a quiet conference room, office or separate room at home for the interview. The majority of the participants were interviewed via WeChat video (a cell phone application) to prevent and control the epidemic, while some participants were interviewed in person after confirming that neither the investigator nor the participant was infected. All researcher–participant interviews were conducted on the day the participant was notified of their release from quarantine in order to minimise recall bias. The interviews were conducted to understand the participants' experiences and feelings and lasted approximately 30–40 min. The participants’ consent was required for recording the interviews, and the notes that could not be recorded were documented on paper. Additionally, some unclear questions were properly rephrased and further explored. Aside from providing guidance on the questions, the researchers did not express their opinions during the interviews. After the interviews, the voice recordings were transcribed to provide written materials. Following transcription, the researchers checked the contents of the interviews to ensure the authenticity of the materials. Data were collected until no new topics appeared, that is, until the interview data had reached saturation.

Semistructured interview schedule:

1. What was your first reaction when you learnt that you were in close contact with an infected person?

2. How did you feel when you learnt that you would be forced into quarantine?

3. What was your experience during quarantine?

4. What difficulties or obstacles did you encounter during quarantine?

5. How will this experience affect your future work?

Data analysis

After the interview, the contents were imported into NVivo V.12 software for text data collation, and the final cumulative interview time was 453 min, with 86 450 words transcribed. The data analysis was conducted using Colaizzi’s method,¹⁷ with the following steps: (1) sort the recordings and observation materials into written materials, (2) identify themes by reading the records carefully and repeatedly, (3) code recurring and meaningful ideas, (4) collect the coded themes, (5) write a detailed, complete description, (6) identify similar views and (7) verify the responses with respondents. The same data were analysed by at least two investigators, and themes were extracted.

HCui and HChen conducted the interviews. HCui has attended qualitative research courses at Cambridge University and Fudan University, and HChen has attended the qualitative research training class at Fudan University. After collecting the data, they recorded or transcribed it in a Word document, which was checked repeatedly by SS and YL. The data were imported into the software and analysed by at least two investigators (HCui and HChen). Moreover, BS and HL, senior professors in qualitative research, selected the themes. After the themes were confirmed, the participants were checked, and if there were any disagreements, the themes were extracted again to form the final data. All data were anonymised in this process to protect the researchers’ judgement.

Patient and public involvement

Neither the patients nor the public were involved in the design, or conduct, or reporting, or dissemination plans of this research.

Characteristics of the participants

We recruited 15 participants, including 5 doctors and 10 nurses. In China, doctors and nurses represent over 70% of the total hospital staff. Among the front-line HCWs, we focus only on doctors and nurses, since it directly face patients during the pandemic and have the highest likelihood of close contact. Table 1 presents their demographic details.

Table 1.

Demographic characteristics (N=15)

Characteristics	N	%
Occupation
Doctor	5	33.0
Nurse	10	67.0
Age (years)
18–30	5	33.0
31–40	7	47.0
41–50	3	20.0
Gender
Male	2	13.0
Female	13	87.0
Marital status
Unmarried	6	40.0
Married	8	53.0
Divorced	1	7.0
Professional title
Primary title	9	60.0
Middle title	5	33.0
Senior title	1	7.0
Education
Associate’s degree	5	33.0
Bachelor’s degree	3	20.0
Graduate degree	2	14.0
Doctoral degree	5	33.0

Results

Thematic results

This study identified four themes: (1) personal psychological changes, (2) increased reflection on life and work during quarantine, (3) the important role of others’ support and (4) different types of needs in the quarantine process. Additionally, each theme was supported by several subthemes, illustrating the real experiences and needs of the participants (table 2).

Table 2.

Themes and subthemes

Themes	Subthemes	Quotes
Personal psychological changes	Shock, suspicion Anxiety, fear Worry, guilt Frustration Isolation	I just froze, and I was shocked, that I was in close contact, and I wondered if there was a mistake. I was afraid that I had been infected by any link. My main concern was the anxiety of being locked up in a closed environment for a long time. I was so worried about infecting my husband that I felt guilty. There were too many things to do that day. Later, my superiors held a meeting and criticized me. After I was identified as a close contact, I felt like the people around me stopped talking to me, and they kept a distance from me.
Increased reflection on life and work during quarantine	More attention should be paid to personal protection in future Individuals owe their families and need to shift their focus once the pandemic is over A sense of personal responsibility and increased professional pride Changed perceptions of doctor–patient, doctor–nurse and support staff relationships	In the future, I will implement personal protection more seriously and pay attention to hand hygiene. I may shift my focus to spend more time with my family. I am quite proud of myself because I have experienced an epidemic and participated in this struggle. We rarely pay attention to our aunts and uncles who clean and deliver specimens, but they are the ones who are willing to pass on their kindness when we are in trouble.
The important role of others’ support	Peer support Social support	Dr. Chen asked us to chat more in the WeChat group. If we have something special to report, it makes us feel like we're not alone. During quarantine, I played video games with my friends daily, which I think was quite useful in relieving my anxiety.
The different types of needs in the quarantine process	Material needs Need for spiritual comfort Information needs	I was suddenly told to quarantine. I did not bring anything. I still hope to guarantee some basic life supplies. I also hope to get spiritual and psychological support. A lot of negative news from the outside world has caused me great psychological distress, but no one has come out to explain and clarify the situation.

Theme 1: personal psychological changes

Shock, suspicion

The first reaction of some interviewees after being classified as close contacts was shock and denial. They were surprised that they had been in close contacts with COVID-19 patients, and that they had doubts.

My colleague, who had been fine during the day, suddenly told me that she was a patient, and I was in her room, and I just froze, and I was shocked, and I was in close contact, and I wondered if there was a mistake. (Participant 1, 26 years)

Anxiety, fear

Most participants reported feeling more anxiety and fear than ever before, primarily because they had been in close contact with patients and felt more anxious and afraid of becoming infected, which gradually disappeared as the nucleic acid tests showed that they were not infected. Several participants expressed anxiety over the isolation point’s space. Moreover, some participants reported that their anxiety was related to the loss of learning opportunities.

I am afraid that I may be infected by any link, especially when I am waiting for nucleic acid. When the test result is good, I will feel better. (Participant 3, 38 years)

I am in the infection department, I understand the characteristics of this virus, including the detection method, and I feel that the possibility of infection is not big. My main concern was the anxiety of being locked up in a closed environment for a long time. (Participant 10, 35 years)

I participated in the fight against COVID-19 in 2019, so I have a certain understanding of the virus. Because I was in close contact with the environment, I think the possibility of infection is unlikely. I am not worried about this aspect, because I came to Shanghai for further study, and the time for further study is coming soon. It was difficult to learn some advanced knowledge and technology, and at this point, I feel very anxious. (Participant 8, 35 years)

Worry, guilt

Most participants expressed concern about their families. They also worried about their colleagues with whom they came into contact, and expressed some concerns about work.

I had just returned home to deliver supplies to my husband. I was so worried about infecting my husband that I felt guilty. I thought I should not go back to deliver supplies because at least one person would be safe. I also dare not tell my parents, because I am the only child, and afraid the old people worry, since they are not in good health. When I spent my birthday in quarantine, I watched my parents celebrate my birthday through the camera at home. I couldn't say anything and couldn't stop the tears from flowing. (Participant 15, 29 years)

My condition is nothing, but I am afraid of my colleagues who were with me. I took off my mask, in case my condition is not good, I am especially worried about spreading it to others. (Participant 7, 21 years)

I was judged to be a close contact and my reaction was that I couldn't go to work. Originally, there were not enough people in our fever clinic. I was worried about affecting other people’s schedules. I could not come, and my colleagues would have to help me to work, so I was worried about some things at work. (Participant 10, 35 years)

Frustration

Some participants said that there was confusion in management because of the sudden outbreak of the epidemic, and the employees were criticised frequently, which made them feel frustrated and wronged.

Because the patient appeared in the ward, the people in one of our departments were judged as close contacts. My colleagues and I were quarantined in the ward. As the head nurse, I was responsible for arranging all the things in the ward, but no one told me what to do. There were too many things to do that day, and I was a little late to do nucleic acid. Later, my superiors held a meeting and criticized me, asking me why I was so late. I really don't want to be a manager anymore. (Participant 13, 49 years)

Isolation

Some participants reported feeling ‘isolated’ from others when they were judged to be close contacts.

After I was identified as a close contact, I felt like the people around me stopped talking to me, and they kept a long distance from me, as if I had become sick and could infect them. Then I called back to the community and wanted to go home for quarantine, but they also refused. I felt isolated and uncomfortable. I felt that I had made a contribution to the fight against the epidemic, but the people around me isolated me. (Participant 9, 33 years)

Theme 2: increased reflection on life and work during quarantine

More attention should be paid to personal protection in future

After this experience, many participants said that they would pay more attention to their own safety, especially in public places.

After this event, I reflected carefully on whether I had done a good job of personal protection in the past. I think there are still problems with this. In the future, I will implement personal protection more seriously and pay attention to hand hygiene. (Participant 4, 26 years)

Individuals owe their families and need to shift their focus once the pandemic is over

More participants said that they owed their families and would spend more time with them after the pandemic to compensate for their regrets.

After this event, I will cherish the time I’ve spent with my family, and I may shift some of my focus to spend more time with my family. All these honours and things are false. What can accompany me through this difficult time is the support of my family. (Participant 11, 39 years)

A sense of personal responsibility and increased professional pride

Some participants said that participating in the fight against the epidemic did not result in many negative thoughts. According to them, it was their responsibility and mission, and this experience would motivate them to move forward in their career.

Although I have been in close contact, I am willing to participate in the fight against the epidemic when I go out. On the one hand, this is the responsibility and mission of our medical staff. On the other hand, to be honest, I am quite proud of myself because I have experienced an epidemic and participated in this struggle. I feel that my career is glorious rather than ordinary. (Participant 1, 26 years)

Changed perceptions of doctor–patient, doctor–nurse and support staff relationships

As a result of this intimate experience, the participants re-examined their relationships with patients, better empathised with patients and their families and built closer relationships with doctors, nurses and support staff.

While in quarantine for being in close contact, the director asked me to make a return visit to a former patient. Because the entire city of Shanghai was closed, patients from outside the city could hardly come to the hospital. The parents were really touched when they received the phone call, and I was able to answer some of their troubling questions. This made me think that when I was quarantined, I still had many needs, and patients may face a more difficult situation. In the past, I hated patients adding my WeChat, but I think in the future, I would like to give my WeChat number to them, and try my best to help them. (Participant 6, 42 years)

In this quarantine, the two head nurses did set an example. They actually lived in the department before the closure management. Why did they live in the department? They were afraid that they will not be able to come back to work after going back. This spirit was very commendable, and they helped everyone arrange properly, which makes me admire them very much. The young nurses below are really good, without complaint, which increases my understanding of the nursing team. (Participant 5, 50 years)

During the quarantine period, once the box lunch was less than a portion, I had no food to eat, but the logistics uncle next door gave me an egg, I was particularly moved. We rarely pay attention to our aunts and uncles who clean and deliver specimens, but they are the ones who are willing to pass on their kindness when we are in trouble. (Participant 15, 29 years)

Theme 3: the important role of others’ support

Peer support

Respondents reported feeling supported by their peers at quarantine sites during the quarantine process, which gave them renewed confidence to continue fighting.

Dr. Chen, the team leader during our quarantine period, would ask us what we needed on WeChat, and from time to time, he asked us to chat more in the WeChat group. If we have something special to report, it makes us feel like we're not alone. (Participant 2, 34 years)

Social support

During the quarantine process, some respondents said that they felt supported by friends and leaders, which encouraged them to get through this difficult time.

During quarantine, I played video games with my friends every day, which I think was quite useful to relieve my inner anxiety. (Participant 10, 35 years)

Dr. Xu used to be our old director. After I became a close contact, he gave me a special call to show his concern for me, which touched me very much. (Participant 6, 42 years)

Theme 4: the different types of needs in the quarantine process

Material needs

The interviewees expressed their hope that the leaders or hospitals would provide them with the most basic living necessities during the quarantine process.

I was suddenly told to go into quarantine. I didn't bring anything. Because I was quarantined in the quarantine point of the hospital, the conditions were relatively simple, there was no protective equipment, so I brought a sleeping bag. During the quarantine, I caught a cold, I still hope to guarantee some basic life supplies. (Participant 12, 28 years)

Need for spiritual comfort

The interviewees expressed their desire to receive spiritual support and to reduce their psychological burden in the process.

In addition to the material help, I also hope to get spiritual and psychological support. Because of being quarantined, the psychological burden of this process was still very heavy. (Participant 1, 26 years)

Information needs

The interviewees expressed that they preferred to receive clear and transparent information in the process, and did not want to be misled or influenced by misinformation or bad news.

We don't have clear information about the quarantine period at all. One said that the quarantine period was 7 days, the other said that the quarantine period was 14 days. No one gave clear instructions on when we would go out, and the information we got from the outside world was not in line with the actual situation. A lot of negative news from the outside world has caused me great psychological distress, but no one has come out to explain and clarify the situation. I hope to get some accurate and transparent information, and not to be deceived about the real situation of the epidemic at this time. (Participant 14, 35 years)

Discussion

Psychological problems associated with COVID-19 include depression, anxiety, stress, panic disorders and other psychological changes, and HCWs face higher levels of psychological problems,^{18 19} which is consistent with our results. Lu et al²⁰ reported that the psychological status of medical staff during the COVID-19 pandemic showed greater fear, anxiety and depression than administrative staff. Unlike ordinary contacts, HCW contacts have to face not only family and friends, but also front-line colleagues and clinical patients. During quarantine, they reflect on the psychological distress of the general population, including fear. COVID-19-related fear differs between patients and quarantined people, with patients being more afraid of social stigma and quarantined people being more afraid of contracting COVID-19,²¹ which is consistent with our results. Moreover, worry was a psychological condition for many HCW contacts, while fear of infecting relatives with SARS-CoV-2 was one of the biggest stressors for hospital workers.²² HCWs and patients infected with COVID-19²³ face stigma. In this study, the respondents felt isolated by others around them; they felt that they contributed to the fight against COVID-19 and were under great pressure, but they were also discriminated against by others, producing more uncomfortable feelings. This is consistent with Chen et al’s²⁴ research. Additionally, HCWs face the responsibility of their jobs, resulting in feelings of guilt for their patients and colleagues, as well as frustrations with injustice at work. People in different positions have different concerns and demands, for example, front-line HCWs have different responsibilities than regular HCWs. A study²⁵ in China found that nurses were at greater risk of depression and anxiety than doctors. Nurses need more psychological support to cope with pressure and maintain their mental health.²⁶ Therefore, it is essential to identify psychological dilemmas individually according to different occupations and positions in order to provide precise psychological intervention support to medical staff contacts.

The role of peer support and social support should be emphasised in this process, which is defined by the Mental Health Council of Canada as ‘a supportive relationship between people who have a lived experience in common … in relation to a mental health challenge or illness … related to their own mental health or that of a loved one’.²⁷ Currently, such support is widely used in breast feeding²⁸ and emergency nursing to alleviate intense sentiments.²⁹ Peer support can improve an individual’s empathy and self-efficacy,³⁰ as well as their psychosocial well-being by increasing social contact and strengthening their emotional resources.³¹ In this study, the participants also described the encouragement and support from their peers, which made them feel comfortable. Social support—defined as the provision of financial, instrumental, emotional and/or psychological support to others through social networks, such as family members, friends and community members—also played an important role.³² A survey of Chinese adolescents during the Omicron epidemic showed a negative relationship between social support and the occurrence of negative emotions.³³ Social support reduces loneliness,³⁴ and social support from partners, family and friends reduces emotional distress, such as depression, anxiety and neurotic breakdown,³⁵ which is consistent with this study. In this study, family members, mentors and leaders showed care and sympathy to close contacts, which greatly calmed their emotions. Therefore, future works should focus on providing peer and social support, providing care for close contacts, relieving their tension, anxiety and other negative emotions and building confidence.

Moreover, policy-makers and managers should not only consider the spiritual comfort needs of medical staff contacts, but also their material and information needs. Healthcare personnel accounted for 20%–40% of the SARS cases, and inadequate personal protective equipment (PPE) increased the risk of infection.³⁶ Access to adequate PPE can ease HCWs’ perceptions of susceptibility to COVID-19 and help maintain their mental health.³⁷ In this study, many participants commented on the lack of antiepidemic materials, which increased their psychological burden. Additionally, the need for information should not be ignored. Evidence shows that adequate information from public health institutions reduces psychological distress.³⁸ In this study, medical staff contacts expressed their desire to receive recent, accurate information, since inaccurate information increases their anxiety.

Finally, HCWs contacts should be provided with incentives and positive guidance to enhance their sense of professional benefit. Herzberg first proposed the two-factor theory in 1959.³⁹ According to this theory, two types of factors influence individual activities: hygiene factors, which refer to eliminating factors dissatisfying the employees, including the management system, post supervision, working environment, welfare treatment and interpersonal relations; and incentive factors, which help employees to maintain high enthusiasm and initiative as well as improve their quality of work, including social recognition, incentive policies and career promotion. In the study, some participants were criticised by their leaders for dealing with matters too late under special circumstances, which discouraged them to engage in such work. Some participants lost their passion for future work because of public’s incomprehension and stigmas. Conversely, those who received help from others and those who felt proud to fight the pandemic were enthusiastic about their future careers. Therefore, it is imperative for managers to not only eliminate the factors that make the staff dissatisfied, but also provide positive incentives in order to maintain a positive attitude, feel the benefits of their profession and intensify their propaganda. Allowing medical staff to feel a sense of social identity can reduce their negative emotions and experiences; however, reducing the turnover rate of doctors and nurses is crucial for ensuring the normal operation of medical work.

Since most of the interviews were conducted via video calls due to pandemic restrictions, we could only record changes in the participants’ facial expressions. Thus, it was difficult to observe their body movements, and more detailed information may have been lost.

Conclusions

Quarantine of individuals in close contacts with infected individuals is necessary to prevent the spread of the disease. This process is long and painful, particularly for HCWs, who are at a greater risk than the general population. Our findings not only demonstrate the psychological reactions of ordinary close contacts, but also reflect on the unique feelings and experiences of doctors and nurses during the epidemic. Moreover, future works will require multidepartment cooperation to assess their needs, provide individualised care and love and offer incentives in order to reduce their psychological burden, improve their quality of life and enable them to engage in healthcare with a healthy mind.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The Institutional Ethics Review Board of Shanghai Children’s Medical Centre (SCMCIRB-K2022082-1) approved this study. Informed consent was obtained from the participants, and they had the right to withdraw from the study at any time with no adverse consequences. The interviews were conducted after obtaining signed informed consent. Before the in-depth interviews, the participants were numbered, and their data was kept secure to ensure anonymity and confidentiality. Participants gave informed consent to participate in the study before taking part.