Anxiety due to uncertainty of COVID-19 and media exaggeration

All study participants reported experiences of immense fear and anxiety due to the uncertainties around COVID-19 at the onset of this outbreak in Pakistan. It was primarily triggered by lack of knowledge, prevalent misconceptions about COVID-19 and being aware of its disastrous effect in the developed world. There was a perception that it was a fatal virus and whoever got it would die. Others were sceptical about its existence, like how long this outbreak will last and if they will remain bound forever to the new operational changes in service delivery.

At the beginning, the real fear among people was that—a rumour spread that, if God Forbids, this much dangerous disease, and someone gets it he will die. (Health manager, Ghotki)

There’s a bit of worriedness, mental pressure, what to do what not to do, how to go, should we go to their house or not, these problems happens, mental stress occurs. (LHW, Jamshoro)

A large majority of HCWs were not able to distinguish between COVID-19-positive and negative people around them due to their asymptomatic characteristics and lack of testing facility which was mentally disturbing. It made the HCWs reluctant to interact with patients and community members, and even with their colleagues at the very beginning of the outbreak. This was consistent among facility-based service providers, health managers and LHWs.

We ourselves were also mentally disturbed, that how do we know, we are going on duties, on fields, we staffs are meeting each other so how do we know that who has corona symptoms and who does not. (LHS, Rawalpindi)

Fear of infection, isolation and stigma

While most of the PHCWs were not directly involved in providing care to patients with COVID-19, there was still some fear of being contracted with COVID-19 during their interaction with patients at the beginning and during peak time. Similar fear existed among LHWs during their routine household and targeted visits for contact tracing.

We were afraid that we might get infected or our families might get infected. So we spend all this time under stress. We were seeing that there were many positive cases in our neighbourhood and the news on media. (Health manager, Shaheed Benazirabad)

Some of the facility-based staff were seconded to COVID-19 isolation centres. It was highlighted that the level of fear was considerably higher among them. Similarly, the level of fear of possible transmission was higher among HCWs who had any chronic disease (eg, diabetes) or had old parents or young children, be they working at the health facility or in the community.

At that time, my female health workers were very disturbed mentally. She was like we have small kids how we will run out-patient services… how everything will be managed. Their families were also tensed that you are going on duties and you are putting us on danger as well. (Health manager, Shaheed Benazirabad)

These stressors and uncertainties of being infected also affected the provider–patient interaction during the initial phase of the outbreak and as it peaked. A service provider shared that:

When a person is mentally unwell and is feeling uncertain, then s/he wouldn’t even deliver what is normally expected of him/her. We were not able to take care of the patients then. We didn’t know whether the incoming patient is COVID positive or not. We just kept a distance and asked patient ailment. We had to save ourselves someway. (Service provider, Faisalabad)

Fear of isolation was not reported by many HCWs. Only a few facility-based service providers reported to be stressed as they had to stay away from their family members, or by being alone.

She [my co-worker] took her medicine regularly for 14 days at home. Then her [COVID-19] test was conducted after 14 days and it came negative. But still she was very worried and tensed, and she was crying that she had to stay away from her kids. (Service provider, Khairpur)

Mixed responses were reported by the LHWs in terms of stigma faced by them. According to some LHWs, community members resisted their entry into the households, whereas senior or experienced LHWs reported fewer such issues in the field.

During corona [peak] days, when we [I and my LHW] used to go out, people used to complain a lot. A huge pandemic has spread and you are coming to our house, so how do we know whether you have it [COVID-19] or not; you can infect us. We felt this kind of resistance a lot in field even though we used to go with PPEs (sanitizers and masks)… at some places, sometimes it [people’s reaction] was normal and some people gave very positive responses. (LHS, Rawalpindi)

Challenges regarding patients

A major challenge that was a source of stress and frustration among HCWs was uncooperative patients. Facility-based staff were concerned that patients were reluctant to wear face mask or to adhere to physical distancing within the premises of health facilities, and at times they became offensive when they were insisted to take protective measures for COVID-19.

Our stressor was our patients because they were not ready to understand the situation. They didn’t cooperate with us. They thought we didn’t want to treat them. We get the announcement done here in our local areas and also pasted the posters. We also wrote on the board outside to ‘wash your hands’ and ‘wear mask in hospital’; but we had to tackle a lot of troubles like these. (Health manager, Gujrat)

Due to illiteracy, people did not believe in the existence of any viral outbreak, and they considered such protective measures as tactics of health workers to avoid service delivery.

Only those women are worried who are a little bit educated but mostly aren’t, 99% of people are don’t have any fear and they don’t believe in corona existence and they think that we are making them stupid. (Health manager, Mirpur Khas)

Early on, another challenge faced by facility-based staff (both service providers and managers) was to conduct COVID-19 test for suspected patients. According to them, people were extremely reluctant to share any details or willing to undergo COVID-19 test. This was primarily due to the prevalent myths and misconceptions regarding COVID-19 at the beginning of this outbreak.

People used to bring sticks to beat us because it is a rural area and villagers used to say that our patients didn’t have anything and they asked us to go away. We had to call assistant commissioner of that area than he used to send police. After that we were able to take samples from them. It was mental torture for us. Believe me, when we tell people that we are about to take their samples, tell us your mobile number and Identification Card number etc. I swear they curse us and run away. (Service provider, Sargodha)

Stress due to lack of availability of PPEs

Lack of availability of PPEs or supplies put both facility-based and community-based HCWs under immense stress of being infected. Even facility-based HCWs, who were seconded to a quarantine centre, expressed concerns about unavailability of PPEs.

I had duty in quarantine for 3 months then I didn’t have any kit or PPE, or mask or glove. I got a call and they told me to come on duty that day at 2 so I started crying because both my parents were home. We heard about doctors and XYZ deaths. I was scared and didn’t have any protection kit. (Service provider, Sialkot)

In the absence of PPEs, some of the facility-based service providers and LHWs made use of the scarf or linen to cover themselves and their patients’ face or a community member during household visit, respectively, while majority of them reported to have it purchased on their own.

Obviously, there weren’t many masks available for us even and for patients. So any piece of cloth, or scarf, we use to make them cover their mouths and nose. Males sometimes used linen or face mask. (Health manager, Ghotki)

Stress due to excessive workload

Increased workload was mainly the concern of field-based staff (LHWs and LHS) and those who were given additional responsibilities like secondment to COVID-19 isolation centre. Field teams had to locate suspected cases at a short notice. Lack of proper transportation, especially during lockdown, made things quite stressful and exhaustive.

Everybody was busy running to and fro because [COVID-19] cases would come without notice. Doctor would get anxious and ask us to collect data and pictures [of patients]. We had to go to LHS and LHW. (LHS, Rawalpindi)

On the contrary, the workload of facility-based service providers reduced considerably during the initial phase in the health facilities as people were reluctant to go to health facilities in fear of COVID-19 and certain prevalent myths.

Yes, it (health facility) was working but patients were very less. Usually we have 200 or 300 patients but during corona we had only 30 or 40 patients. Even there was news circulating in news channels that poison injection were being given in the hospitals to corona patients. So people were really afraid and due to these kinds of rumours they stopped coming to hospitals. (Service provider, Sargodha)

Awareness raising of HCWs

All facility-based and community-based HCWs reported to have received trainings on awareness raising that were organised by the department. The trainings primarily focused on preventive aspects of COVID-19: characteristics of virus, signs and symptoms, modes of transmission, population at risk, preventive and protective measures, quarantine guidelines and its testing.

The purpose of training was to screen yourself, keep yourself safe, save the people of your organization, and also protect community; things that can control the disease. If a patient has symptoms, tell them where to do test and how it is done. (Service provider, Khairpur)

However, participants from all three study groups unanimously informed that they had not received any training on mental health except for one LHS.

In trainings, we talked on all issues, right. But, the main issue that was not touched is people’s mental condition during corona. Nobody ever tried to assess that amongst us. We have never ever tried to understand people mental level or their mental condition or our feelings. (LHS, Rawalpindi)

According to all HCWs, increased awareness and declining COVID-19 cases over time mitigated the fear and stress among HCWs.

Right now [health] workers are not depressed they are normal and doing their routine work. They were depressed and worried in the beginning but now they are normal due to awareness campaigns. (Health manager, Shaheed Benazirabad)

Provision of PPEs

PPEs were provided to the health workers with some delays, after few weeks of the outbreak in the country. The use of these PPEs, combined with other protective measures of COVID-19, played a major role in reducing fear and stress among HCWs.

We displayed the posters outside of hospitals—informing people not to come to the hospital without any reason. Maintain social distancing, wash hands, make soaps available everywhere and made hand sanitizers available. That’s how we coped up with the stress. To be very frank, in the beginning everything was very difficult for me and for them [health workers]. (Service provider, Multan)

Firstly, protection, masks, shields etc. there was a shortage before but now they are available. There is also awareness now, we are seeing that there are fewer patients in Pakistan compared to other countries. All these things are effective for mental health. (Service provider, Sialkot)

Social support from coworkers and family members

Provision of social support by coworkers—including colleagues and supervisors—emerged as a common response mechanism to mitigate the fear, stress and anxiety among both facility-based and community-based HCWs. During the early phase of this outbreak when stress, anxiety and fear were high, staff members used to discuss and provide social support to each other. Senior HCWs often used to enquire about challenges being faced by their colleagues, including if they were emotionally disturbed. They used to console them to help overcome any kind of fear, stress or anxiety pertaining to COVID-19.

We just provided them emotional support. I educated staff members that we are health care providers, how could we help people if all of us become a victim of mental health issues. We have to be strong because we are on frontline. We don’t have to be fearful. Along with that we used to appreciate workers. What if they themselves become depressed then who would work. I told them that corona has no limit so we will have to live with it. (Health manager, Khairpur)

A couple of HCWs acknowledged that they used to consult and take frequent advice from ex-physiatrist mates to overcome stress, and some received support from their family members.

I was in contact with a psychiatrist so in that way I used to get constant help from there. I personally took many sessions. (Service provider, Faisalabad)

My husband kept on telling me that the night that is in the grave is not outside, so stop thinking about it and the major support that my husband gave me was it is a death by martyrdom so I used to get relaxed from that as well. (LHS, Rawalpindi)

The emotional support was provided in several ways. Some of the consoling approaches were: (a) reinforcement of the use of PPEs and COVID-19 standard operating procedures (SOPs); (b) reiterating the purpose of being a health worker; (c) ensuring frequent communication with the stressed person and giving assurance of being with them; (d) motivating colleagues by giving their own example; and (e) encouraging others to keep themselves busy if they are stressed. Importantly, some used religious healing perspective by linking everything with God ‘Allah’, that He will take care of everything.

All you have to do is care, and this is a type of help and if any patient gets well with our help it would be a blessing from Allah, living and dying is Allah’s decision, we can only take care so take care and help others, you will be rewarded InshaAllah [if Allah wills] so we say all this to each other and we give support to each other. (Service provider, Dadu)

I was continuously in contact with her [COVID-19 positive health worker] and tell her to take care of herself and she was telling her children whether test will come negative or not. She was scared that she had corona and she would die. Yes, we told her God will help you. We have doctors with us and our district manager and medical superintendent are with us, they were talking to her continuously. They were also consoling here that corona will end why you are worried? (Service provider, Khairpur)

Reassuring, giving trust, and with positive thinking for the future, telling them that we are messengers, Allah has placed us to serve these people, to take care of them, to tell them preventions. (LHS, Rawalpindi)

A few facility-based HCWs kept themselves busy in extracurricular activities to deal with their stress, like reading or even social media.

I kept myself engaged because whenever I was free then I would get a lot stress when you hear news etc. I was studying and spent most of my time with my co-worker. And whenever I would go home, I would keep myself engaged mentally. (Service provider, Sialkot)

Managerial support from supervisors

According to a majority of service providers and LHWs, their supervisors/managers provided a lot of support in managing work-related issues that were causing stress. The supervisors primarily managed issues of their teams by themselves, or at times, by engaging higher (district) administrative health authorities. Effective communication with team that included constant motivation and awareness raising was instrumental in addressing day-to-day challenges. At some instances, health managers also offered intermittent breaks to the health workers who were unwell or became exhausted due to work. A couple of respondents also mentioned that the health facility was closed for a few days when the COVID-19-positive staff were quarantined.

We fulfil their demands, if there is a salary issue, if they haven’t received their salary from 2 to 3 months, we write it to DHO that they will not do work with interest so they should be given their salary on time and they forward it to upper department and their problems are solved. (Service provider, Dadu)

I counsel them that see this is difficult for us; you cooperate with me and I will cooperate with you. If you have any problem then you can tell me and take off. If there is no issue then take half day off but come to work next day. So I tried to make them relax like this. (Health manager, Karachi)

Safe and conducive working environment

Safe working environment was identified as one of the prominent needs of both facility-based and community-based HCWs. It primarily meant timely provision of PPE kits that should include gloves, face masks and hand sanitisers, and provision of security especially in dealing with aggressive patients.

We should have received PPE kits in the beginning before [COVID-19] peak time. When cases were increasing in China, since then we should have made ourselves prepared for this. (Service provider, Multan)

Security should be given especially in this COVID situation. Because when patients come to the health facility and the doctor fails to examine them then they create a scene or become aggressive, and misbehave. (Service provider, Sialkot)

Primarily, facility-based HCWs who were assigned additional responsibilities related to COVID-19 expressed a dire need of intermittent breaks under certain circumstances—for example, when a worker is ill, exhausted due to increased workload or experiences any kind of stress.

If someone appears COVID-19 positive then that person is placed in 14 days quarantine. So if he is already in a stressful condition, his mental health isn’t able to hold so at least until he is normalized, there should be some relief given. (Service provider, Faisalabad)

They [health workers] say that how can we perform our normal duties and COVID ward both simultaneously? So they should be given holidays. Our demand is that our staff should be given more holidays and good packages and some financial bonuses should be provided. (Health manager, Mirpur Khas)

Awareness about evolving situation of COVID-19 and corrective actions

A majority of facility-based and community-based HCWs expressed the need for having updated information about the evolving situation regarding COVID-19. They also identified the need of receiving timely guidelines about the corrective actions in dealing with constantly changing situation.

There should have been sessions about the forthcoming epidemic. Like this what is this disease, what are its consequences, how to deal with it. There should’ve been such learnings that they prepare their workers. They just said that ‘wear masks’, and what’s being told on TV. (Health manager, Khairpur)

Psychosocial support from specialised mental HCWs

Even though social support emerged as a key response measure used by HCWs to cope with the prevailing stress, getting psychosocial help from specialised mental health professional was still identified as a need and future recommendation by majority of the study participants. Various suggestions were given to have such support in place for the HCWs, which included: (a) having a full-time specialist-based district or subdistrict level to provide needs-based support, (b) conducting periodic sessions on mental health, (c) mobile team of psychologists to provide periodic support for health staff and (d) making mental health component a part of the COVID-19 trainings.

Mental health is a drawback here. There should be a proper person, who should, first of all, educate the staff, that how will you improve the mental health of the people. Then, some training should be arranged there, meaning, there should be a proper person sitting there, right, like some psychiatrist, or some people like these. (LHS, Rawalpindi)

In my opinion, CEO of our hospital should depute someone from DHQ like 3 sessions in a week so that they can give sessions to healthcare workers, perform counselling and try to know their inner problems due to which they are disturbed so that their problems can be solved. And provide them relief if it is related to salary or any other issue. (Service provider, Sargodha)

Some facility-based HCWs suggest use of mobile application to provide information about mental health and well-being.

They should conduct seminars and this is the era of multimedia everyone has mobile and there should be more content on multimedia and social media about mental health so that we become mentally strong and cater things properly. There should be seminars and sessions and government should launch an app regarding this so that we get information from it regarding mental and physical health and keep on updating it. (Health manager, Gujrat)

On the other hand, facility-based HCWs expressed the need of capacity building to provide adequate psychosocial support to coworkers and to their patients, as needed. These trainings are also expected to help them guide the general patients or community people to follow COVID-19 SOPs.

No, patients aren’t believing, that’s why psychiatrist is important and there should be training provided by the psychiatrist. Our staff should be provided psychological training, we should know what they [patients] are saying and what their opinions are so then we can handle them accordingly. (Health manager, Mirpur Khas)

Appreciation and recognition of their work during the pandemic crisis

Both facility-based and community-based HCWs demanded recognition and appreciation for the additional work that they had to do during the COVID-19 crisis. This need was particularly highlighted by those who were given additional responsibilities like secondment at isolation centres, contact tracing and COVID-19 testing of suspected cases. This recognition was demanded in the form of monetary incentive for risking their lives, or a letter of appreciation by the health department, or a continuous encouragement from their administrative leadership.

Lady Health Workers are already doing extra work, putting their lives in danger, should have gotten some extra benefits for this, even if they had gotten any certificate. Even if we get one praise, they want to sacrifice everything. (LHS, Rawalpindi)

I would say that government should facilitate the doctor, increase the allowance, give them a complete personal kit, if someone dies, government should support their family, so this should be on government level, so doctors also work motivated… I would want that government should give full support, financially and morally. (Service provider, Khairpur)