Lived experiences of COVID-19 patients admitted in isolation wards of healthcare centers in Peshawar, Pakistan: A phenomenological perspective

Abstract

The emergence of COVID-19 caused a significant global threat, affecting populations worldwide. Its impact extended beyond just physical health, as it inflicted severe damage and challenges to individuals' well-being, leading to a deterioration in mental health. The lived experiences of patients hold a paramount position to explore and understand their perception of care which can ultimately strengthen the health system's delivery domain. This study explores the lived experiences of patients in the isolation ward, their recovery, and the quality of care being provided in the hospital and its effects on their mental health.

Study design

A phenomenological qualitative study using in-depth interviews.

Methods

We conducted 11 in-depth interviews of COVID-19 patients admitted to the isolation ward of the public hospitals of Peshawar, Pakistan. Participants who stayed for a minimum of 10 days in an isolation ward were included in this study. Interviews were transcribed and analyzed using NVivo 12 software and generated five themes through inductive analysis.

Results

Five themes emerged from the participants' lived experiences: Heading towards the hospital, Health Care Quality, Impact on Mental Health, Recovering from COVID-19 and Back on one's feet. These included all the positive and negative lived experiences. Socio-environmental factors along with their experiences of the disease itself and with the healthcare providers guided their reaction which was important conciliators in their experiences during the pandemic.

Conclusion

Based on the findings, the environment of isolation had a major influence on the mental well-being of the individuals involved. Considering the important role of the ward environment in shaping patient experiences and outcomes prompts a reevaluation of healthcare practices and policies. By addressing these factors healthcare systems can strive for greater effectiveness, resilience, and compassion in managing the pandemic's impact on patient care.

1. Introduction

The sudden Coronavirus pandemic enhanced social distancing and self-isolation that has affected all the facets of mental health, emotional health, and psychological and social wellness at the collective level [1]. On February 26, 2020, Pakistan reported its inaugural COVID-19 case, prompting an immediate outbreak declaration. By December 31, 2021, Pakistan had documented over 1,290,000 confirmed cases and 28,909 COVID-19-related deaths [2]. The initial fatality was recorded on March 18, 2020, in Mardan, KP, Pakistan, sparking increased chaos and fear within the population [3].

During the COVID-19 pandemic in Pakistan, rates of depression stand at 33 % (72.9 million), anxiety at 40 % (88.4 million), PTSD at 34.9 % (77.1 million), and stress at 27 % (59.6 million) [4]. At the first site in Pakistan coronavirus was spread through students, visitors, and pilgrims from other countries. According to the culture of Pakistan, the basic family division is an expanded blood-related system with several peers living together, and thus in a collectivized culture, this social distancing creates a contest on the mental health of all the family members [5,6]. People may encounter worry of death, be afraid of catching themselves or their family's infection, anxiety, anger, depressive symptoms, and other mental health concerns during this pandemic [7]. The COVID-19 pandemic coupled with social stigma and out-of-pocket expenses has harmed our society hindering and discouraging patients from seeking much-needed medical care [6,8].

Pakistan, being a lower and middle-income country (LMIC), faced the COVID-19 pandemic with an already weak health infrastructure and an overburdened healthcare system [9]. Lack of healthcare professionals especially those trained for such emergencies and pandemics, lack of personal protective equipment, no treatment guidelines for initial cases of the pandemic, and fear of dying associated with isolation significantly impacted the dynamics of the mental and physical health of the whole nation and healthcare governance in the country [10].

From the health system standpoint, the lived experiences of patients provide valuable insights and perspectives that are crucial for health system improvement and to development of more patient-centered care strategies. Integrating the lived experiences of COVID-19 patients into health system refinement in LMICs can shape healthcare policies and empower patients and societies for decision-making.

This study examines the mental health burden of the Pakistani public during the COVID-19 outbreak and assesses the coping strategies of the healthcare system. It aims to provide data for targeted interventions. The qualitative research focuses on the recovery experience, healthcare center opinions, and patient resilience in an isolation ward of a public hospital in Peshawar. It explores patient perceptions of hospital experience, quality of care by healthcare workers, staff attitudes, provision of food and medicine, and the impact on mental health during their stay. Also, evaluates the performance of the health system during the pandemic peak, addressing a knowledge gap in Pakistan. It offers valuable insights for improving isolation ward services based on patients’ perspectives.

2. Methodology

2.1. Study setting

The study was conducted in the public hospitals of Peshawar Khyber Pakhtunkhwa (KP) province of Pakistan from March 2021 to October 2021.

2.2. Study Design

The phenomenological approach was used employing 11 in-depth interviews guided by the data saturation from patients purposively selected.

2.2.1. Inclusion criteria

Patients who had result of positive-PCR for COVID-19 and stayed in the isolation ward of hospital for minimum of 10 days and above were included. It was ensured that the total participants had reasonable gender and age diversity.

2.2.2. Exclusion criteria

Patients who had any previous history of mental or psychological disorder, patients with speech problems or communication issues, and the COVID-19 positive patients who did not want to be a part of study (uncooperative patients) were excluded.

2.3. Data collection

The data was collected from the individuals who were affected during the first wave of Covid-19 and consented verbally over the telephone call considering the covid lockdown. Telephonic interviews lasting 30–40 min were conducted in the local language for the participant's convenience. All the transcripts were translated into English and proofread, and the data was analyzed using NVivo 12 software, through an inductive approach.

The interviewer reflected on her experiences and perspectives of the phenomenon she had during COVID-19 at different points in time. It was done through Reflexivity while writing about the experiences and perspectives leading to developing their understanding and intentionally setting them aside while interviewing the participants and understating their experiences objectively during analysis [11]. The process of bracketing was an attempt to achieve trustworthiness during data collection and analysis.

The line-by-line method allowed the researchers to identify the significant statements of the participants' experiences and the selective approach helped reveal the nature of the lived experience. Furthermore, for isolating themes from the interview transcripts, the researchers used highlighting and wholistic approaches [12]. The participants' experiences in isolation wards of healthcare centers were explored after reading the interview text many times in its entirety. In addition, significant words, phrases, and statements about the phenomenon were highlighted to explore the participants’ experiences of the phenomenon that were coded for the identification of the important thematic aspects.

3. Results

3.1. Study participants characteristics

Amongst the 11 participants, eight were males and three were females. Table 1 presents the characteristics of all study participants.

Table 1.

Socio-demographic characteristics of study participants.

Code	Age	Gender	Marital status	Education	Duration of Admission in Isolation Ward (days)
P1	23	Male	Married	Bachelors	12
P2	23	Female	Married	Bachelors	13
P3	52	Male	Married	Masters	22
P4	39	Male	Married	Bachelors	13
P5	36	Male	Married	Bachelors	13
P6	76	Female	Married	Masters	17
P7	35	Male	Unmarried	Masters	11
P8	74	Male	Married	Bachelors	10
P9	30	Male	Married	High school	14
P10	60	Female	Married	Uneducated	15
P11	38	Male	Married	Bachelors	11

After the in-depth interview and analysis, the below-mentioned five themes emerged reflecting on the lived experiences of the patients.

3.2. Heading towards the hospital

Under this theme patients had expressed their feelings regarding going to the hospital to being admitted to the isolation ward, including anger, confusion, stress, and hopelessness, and whether they will be able to see their family again or not.

Many participants displayed negligence and irresponsibility towards COVID-19 before their diagnosis. Some believed it to be a rumor or not a serious disease. People initially disregarded precautions and SOPs, leading to self-isolation at home, which resulted in feelings of loneliness and helplessness. Fear of visiting hospitals contributed to deteriorating health conditions.

“… First, I did not know what type of disease it is, then later when I came to know that, so I was scared. If I recovered its good otherwise, I will be in graveyard. And I was unable to see my children. I had to be alone and that made me cry.” (Pt.10-Female-Line-20-22)

Upon admission to the isolation ward, participants faced an unpleasant situation, experiencing doubt, stress, and depression. They were unsure if they would survive or be reunited with their families. One participant tearfully described their reaction upon seeing the isolation ward, expressing concern about returning home. Male participants, as primary earners, worried about the financial challenges their families would face if they did not survive.

“… On the first day have an isolation word I was sitting on the bed and started crying. I was thinking that what will happen next it was crying like children never seeing them that I do not want to stay in hospital in want to go home.” (Pt.6-Female-Line-28-32)

“ …. the only tension was that my children are too young and my wife from 2008 is psychiatric patient still she is, 2021 is going on, this was only thought that if I die then my wife will go mad, and my children are small my son is of 8 or 9 years, they are too young to manage life.” (Pt.4-Male-Line-23-26

3.3. Health care quality

The study participants expressed overall satisfaction towards the facilities provided to them in the hospital and mentioned that the behavior of nurses and doctors towards them was very good, indicating a positive experience. Both positive and negative lived experiences are expressed in this theme.

Many participants praised the proficiency of doctors and staff in the isolation ward, highlighting their prompt admission and regular presence. The healthcare providers demonstrated a positive attitude, providing timely and appropriate treatment. Satisfactory performance was attributed to specialized training received by doctors and staff in managing COVID-19 patients.

“… Yes, all the medicine were available, and doctors were dealing with their patients. Doctors and nurses used to come and ask me if I need anything or not, and their behavior was good.” (Pt.8-Male-Line-31-32)

Participants generally found the isolation ward in the public hospital to be comfortable, with adequate infrastructure. Triage was implemented to separate COVID-19 patients from OPD patients. The isolation ward provided various services and fulfilled participants' special needs, including portable x-ray and ultrasound machines.

“… Whatever need was of patient was fulfilled; they did 2 times my Xray in room also ECG ….I think that everyone was treated equally in ward, the medicine, which was given to me, the antibiotic, injections which were given, all patients were getting same treatment.” (Pt.5-Male-Line-64-67)

Despite the positive aspects of the isolation ward, participants expressed some complaints. One participant mentioned the need to repeatedly call staff for medicines and other requirements, criticizing their irresponsibility and indifference towards patients. Another participant highlighted that doctor exhibited fear towards COVID-19 patients, resulting in infrequent rounds and brief morning visits.

“ …. Nurses were careless about my medicine timings until I reminded them. Due to that one day, I argued with nurses that they do not ask me about medicine and medicine which were included in my treatment I got them late and even for thermometer and syrup I used to receive them after 2–3 days”. (Pt.1-Male-Line-36-38)

3.4. Impact on mental health

Within this theme, the comprehensive accounts of patients are documented upon their return to home following recovery. However, they encountered various post-covid complications, some experienced stigma, and there were those who diligently adhered to SOPs.

Most of the participants were generally satisfied with the treatment in the isolation ward, experiencing minimal fear or anxiety. Seeing the ward's management increased their comfort. Some participants-maintained hope, providing moral support to others. They accepted the reality of life and entrusted their fate to Allah, alleviating worries.

“… No, there was no depression, though I was happy that they were treating me well and nicely, all the medicines which I needed were given to me on time.” (Pt.8-Male-Line-34-35)

The participants who lacked any supportive role from their family and friends during the pandemic experienced severe anxiety and depression, the fear overplayed any optimism they had, leading to a significant drop in their willpower to fight the disease. One participant even felt that being afflicted with the disease was a form of punishment from God.

“… Not only mine everyone relatives etc. used to say that you will not survive as my condition was too bad, but I was also depressed about whether I will survive or die.” (Pt.2-Female-Line-88-90)

Several participants faced stigma within the isolation ward, expressing disappointment with the way doctors and staff maintained their distance. One participant described how even the lower staff would run away, offering water from afar, as if they were dealing with a ghost. This experience of stigma deeply affected them and left them feeling upset.

“… … Doctors on round of ward never came near me I used to see them from far.” (Pt.1-Male-Line-39)

3.5. Recovering from COVID-19

This theme underscores the pivotal role of both family support and the isolation ward in the patient's journey towards recovery. Particularly, participants who received family support expressed remarkably optimistic outlooks regarding their COVID-19 recovery.

The response of most of the participants given about the isolation ward was satisfying. They were satisfied and happy with the treatments they received while admitted in the isolation wards and the attitude of the doctors and paramedical staff with them was empathizing. They gave due credit to the health care workers directly or indirectly involved in their care, as it played a good role in their recovery to their health.

“… Everything was good with me in hospital, all the days I spent in hospital I am still happy, this is very nice feeling if person goes to hospital, and he is sick and when he comes back to home healthy and happy. I was completely satisfied with the work of hospital, and my views are very positive for them.” (Pt.8-Male-Line-49-52)

The maximum role was played by the family, relatives, colleagues, and friends in the recovery of a patient. The moral support given by loved ones was very important for every patient. Those participants who do not have the support of the family made them very depressed and upset and it took a lot of days for them to recover or come out of the depression. One of the participants explained that corona is a disease due to which many of the relationships have deteriorated.

“… Alhamdulillah everyone was very supportive, I am eldest one among my siblings, Alhamdulillah my brother sister gives me respect of father, so they all were very worried.” (Pt.4-Male-Line-102-104)

3.6. Back on one's feet

This theme expresses the patient's post recovery journey in terms of their self-perceived precautions, hygiene practices and expression of emotions while reuniting with their loved ones.

After getting discharged from the isolation ward, when participants were back on their feet, most of them followed strict SOPs such as wearing a mask, using sanitizer, and washing hands, etc. They took all the precautions to stay safe from the COVID-19. For many days most of them self-isolated themselves at home, a stayed away from their loved ones just for precautions. Many of the participants were happy, keeping in mind the feeling of meeting their loved ones waiting for them at their homes.

“… At the time of getting discharged from hospital, more happiness was of this thing that I came back to my children, my youngest son is 3 years old only, when I entered home, their happiness is still in front of my eyes.” (Pt.4-Male-Line-99-101)

The opinion of most of the participants after getting discharged from the isolation ward was like “a person locked inside a black room” for a long period of time. They missed the nature and its colors; the sky, the greenery and the birds chirping around. They only realized it till they were admitted to the isolation ward, how they would miss Mother Nature.

“… When I got discharged from hospital I was so happy that everything was so nice I was happy to see world again like a child I was looking in surroundings, I was feeling like am free from any closed place and was very happy to see plants, sky, buildings shops etc, driver was also saying that you stayed in hospital many days that’s why you are happy outside”. (Pt.6-Female-Line-185-189)

Few of the people who came back home from the isolation ward faced stigma. People stopped visiting their relatives for fear of contracting this disease. One of the participants stated that even after 15–16 days no one came near to her, and people were still scared and were acting like she is a ghost. Thus, it seemed that even though the COVID-19 patients would recover from the disease after thorough medical care but what awaits them is the stigma of being a COVID-19 patient.

“… People in my village were reluctant towards me were even afraid from shaking hand with me, even up till 15–16 days no one came to meet me after a month they were scared, but my own children behavior was good with me.” (Pt.10-Female-Line-40-42)

3.6.1. Universal essence of all themes

Most of the participants’ lived experiences of the phenomenon revealed a sense of fear, negligence, isolation, and helplessness. They were living with certainty and uncertainty of fear of death, and they were doubtful about their safe and healthy return to the family although most of the participants seemed to be satisfied with the health care quality in the centers. However, they survived living with many superstitions that were the product of their specific cultural background despite the positive role of the family, relatives, colleagues, and friends in their recovery process. While being in the isolation wards, most of the participants experienced something like a “person locked inside a black room” and they were yet afraid of COVID-19 after they were discharged from the health care centers.

4. Discussion

The pandemic posed challenges for patients, healthcare workers, and the country's weak health infrastructure, requiring stretched resources to meet growing demands in Pakistan as a developing country. This research study gathered feedback from participants regarding their experiences in the isolation ward of a public hospital during the COVID-19 pandemic. They mentioned the proficiency of doctors and staff, emphasizing their prompt admission in isolation ward and regular presence. They described the positive attitude among healthcare providers and expressed satisfaction with the timely and appropriate treatment they received. This satisfactory performance was attributed to specialized training received by the medical staff in managing COVID-19 patients. Zhenghua et al., in their study mentioned that the proper and uninterrupted supply of personal protective equipment for the prevention and during the treatment of the COVID-19 pandemic was critical. The safety and health of the medical personnel were given paramount importance and was ensured that any medical personnel and paramedical staff who may come in close contact with the patient must have the necessary PPE at hand. The relevant training was provided to the health care workers to enhance their performance [13].

Participants generally found the isolation wards of the public hospitals were comfortable with adequate infrastructure. Triage systems were in place to separate COVID-19 patients from others, and various services were provided, including portable x-ray and ultrasound machines and they felt that their special needs were adequately addressed. Peijin et al., reported the needs and concerns of the patients admitted in the isolation centers. The authors elaborated that being in isolation is a challenging task not only for the affected person but also the immediate family members. However, they were optimistic that strict implementation of cross infection control measures can be implemented to mitigate against the diverse effects of isolation [14].

However, despite the positive aspects, participants raised some complaints. Some noted the need to repeatedly call staff for medicines and other requirements, criticizing their irresponsibility and indifference towards patients. Also, that doctors exhibited fear towards COVID-19 patients, leading to infrequent rounds and brief visits. In her study, Maheen Ayub and colleagues found that a significant number of physicians were hesitant to treat their patients, because of the serious impact of the pandemic affected their mental well-being, potentially impacting the standard of care patients receive. It's crucial to address their apprehensions, not only by offering support and enhancing their working conditions but also by ensuring they are adequately prepared to deliver high-quality care during these challenging times [15].

According to our study findings, when suddenly the death toll began to rise due to Covid-19, a sense of panic and hype emerged. People stayed at home; many lost their jobs, leaving numerous single breadwinners to support their families. Confined to their homes, people became victims of fear and loneliness. The public was fearful of seeking Covid-19 treatment and even those experiencing Covid-19 symptoms were afraid to get PCR tests and suffered from severe anxiety and depression. People were scared to visit doctors, fearing that anyone admitted to isolation wards would not return home. Similarly, Yong Yang, elaborated in his study that with the rising count of COVID-19 cases and fatalities, there's a mounting apprehension surrounding the virus. The absence of a definitive treatment for the novel coronavirus, it's anticipated that the COVID-19 pandemic will persist alongside humanity for an extended period, introducing significant uncertainty into people's lives. These uncertainties invariably heighten the likelihood of individuals experiencing anxiety. Thus, fear of COVID-19 emerges as a significant contributor to anxiety [16]. In the other study Jingjing Gao, mentioned that the COVID-19 pandemic was particularly challenging for those unemployed or with low income, as they bear a heavier financial burden due to restricted physical activity. Unemployment, exacerbated by COVID-19, is a major social issue, documented to instigate fear and anxiety [17].

The study explains that social distancing and isolation challenged individuals' mental well-being, causing fear, anxiety, and psychological distress. Participants in isolation wards experienced constant fear of death and symptoms of anxiety, depression. However, Daniella Spencer-Laitt stated in his study that the correlation between heightened mental health issues and COVID-19 social distancing is evident. Furthermore, most of the research on the mental health impacts of COVID-19 and past pandemics has primarily centered on the disease's direct effects rather than delving into the repercussions of social distancing [18]. Mental health is vital during a pandemic. This study explored participants' mental well-being, revealing diverse responses. Some experienced anxiety and loss of hope, while others remained optimistic and satisfied with care in isolation wards. Those hopeful participants followed healthcare instructions for recovery and family reunification. Giorgi conducted an extensive literature review that unveiled a comprehensive understanding of the intertwined effects of various factors on mental health during the COVID-19 pandemic. These factors include not only social distancing policies but also the impacts of lockdowns, isolation, anxiety, economic hardships, and specific workplace dynamics. By synthesizing findings across multiple studies, Giorgi shed light on the complex interplay of these elements and their collective influence on mental well-being during these challenging times [19].

In this research study, participants shared that even after being discharged from the isolation ward, they continued to face stigma in society. Relatives did not visit them, people avoided shaking hands with them, and the community discouraged interactions with them. As a result of these circumstances, patients became victims of stigma, which had long-lasting mental effects. Likewise, it was mentioned by Javed, in their study that patients recently discharged from isolation centers could face stigmatization and develop a mix of emotions. The reception by society upon leaving quarantine varied for each individual [20]. “It's easy to blame, it's easy to politicize, it's harder to tackle a problem together and find solution together”. (Tedros Adhanom Ghebreyesus- WHO Director-General). The pandemic has led to damaging social and psychological effects, notably stigma and xenophobia. The interplay between the global economy, epidemiological risk, and xenophobic behavior has been observed. Stigmatized patients face social isolation, rejection, violence, and denial of essential services. Assault cases have been reported in some European countries [21].

5. Conclusion

The findings underscore the significant influence of the isolation ward environment on the mental well-being of individuals involved. Through exploring patients' perspectives on the ward environment and their firsthand experiences, as well as assessing the quality of care received, a profound opportunity emerges to enhance healthcare standards across all facilities amidst the COVID-19 crisis. Recognizing the pivotal role of the ward environment in shaping patient experiences and outcomes prompts a reevaluation of healthcare practices and policies. By addressing the factors contributing to positive or adverse experiences within isolation wards, healthcare systems can strive for greater effectiveness, resilience, and compassion in managing the pandemic's impact on patient care. This highlights the urgent need for tailored interventions, resource allocation, and policy reforms aimed at optimizing patient-centered care delivery during these unprecedented times.

6. Strengths

The major strength of this study despite being one of its kind in KPK Pakistan was that the phenomenological approach used helped in describing participants’ feelings, thoughts, mental health, health care being provided to them in an isolation ward, and their behavior in fighting against the disease. Due to telephonic interviews, the chances of transmission of highly infectious COVID-19 disease were zero.

Ethical approval

Ethical approval (Ref# Dir/KMU-EB/LE/000826) was obtained from the ethical review committee of the Khyber Medical University (KMU), Peshawar, Pakistan. All the participants’ consent was taken and the authors ensured the confidentiality of all data.

Funding

No funding/financial support was received.

Declaration of competing interest

No known competing interests were reported by all the authors contributing to this research, either financially or in personal relationships that could potentially impact the reported findings.