Patient’s psychological experiences during and after recovery from COVID-19 pandemic: a phenomenological study in Pakistan

Abstract

Background

COVID-19 is a transmissible and infectious disease with symptoms similar to pneumonia, ranging from moderate to severe. This study investigated the psychological experiences of patients both during their illness and after their recovery.

Methods

The study employed purposive sampling and semi-structured interviews to gather insights from 13 COVID-19 survivors (7 women and 6 men). Interpretive Phenomenological Analysis was used to analyze the interview transcripts. Participants ranged in age from 22 to 62 years.

Results

The analysis identified seven main themes of psychological experiences during the illness, each with several sub-themes. Key themes included denial of the disease, uncertainty about the illness, and psychological distress, which had sub-themes of depression and stress. Other themes included death anxiety, perceived social stigma (with loneliness as a sub-theme), exposure to infection (with restrictions as a sub-theme), and coping strategies (which encompassed active coping and avoidant coping). For experiences post-recovery, two main themes emerged, with eight sub-themes. The first was post-traumatic growth, which included attachment to God, acceptance of death, gratitude (toward God), trust in interpersonal relationships, gratitude toward people, and the significance of life. The second theme was delayed resilience, which involved recovery from insomnia and post-COVID psychological distress.

Conclusion

The study concluded that surviving COVID-19 involves significant psychological challenges both during the illness and after recovery. These insights are valuable for psychologists and counselors in addressing the emotional and mental health needs of COVID-19 patients.

Introduction

COVID-19 has significantly impacted individuals, nations, and globally [1]. The first COVID-19 case in Pakistan was confirmed in Karachi on February 26, 2020. By that date, the number of confirmed cases had risen to 400,000, with around 8,000 deaths reported [2]. The disease starts with mild symptoms such as flu-like symptoms, cough, headache, and fever. It can progress to more severe symptoms like pneumonia, high fever, lung infections, and severe respiratory issues [3]. On March 18, 2020, the World Health Organization declared COVID-19 a pandemic, following over 8,000 deaths across 159 countries [4]. By November 28, 2020, global death tolls had exceeded 1.4 million due to COVID-19 [5]. The elderly and those with underlying health conditions are particularly vulnerable, and children and infants are also at risk. Currently, there are no specific treatments for the virus; management typically involves antiviral and supportive care, isolation, and close monitoring of disease progression [6].

The rapid increase in COVID-19 cases has led to heightened admissions to hospitals, isolation inwards, ICU admissions, and the need for oxygen support. The rising mortality rates and handling of deceased bodies—such as filled graveyards and crematoriums—have been extensively reported through telecommunications, blogs, newspapers, and mass media. These reports have significantly heightened public anxiety, fear, and restlessness. Diagnoses of COVID-19 often lead to disbelief, shock, and a sense of impending death, with hospital admissions sometimes resulting in quarantine for family members and tracing and isolating contacts [7].

The high infectivity and severe outcomes of COVID-19 have resulted in profound negative psychological effects not only on patients and their families but also on the general public [8]. Mental health professionals have highlighted the need for psychological support as part of the core care team for COVID-19 patients [9]. The bio-psycho-social model, which addresses physical and mental health from biological, social, and psychological perspectives, has been reviewed in past studies [10]. In this study, Watson’s Theory of Human Caring was adapted to conceptualize the phases of study and to determine the psychological experiences of survivors of COVID-19. This Theory of Human Caring emphasize on the factors that affect humans and places and their existence in specific situation. COVID-19 has been impacted the life of survivors in many ways. In this regard, Watson’s Theory of Human Caring give a better understanding related to the experiences of the survivors. This theory has been used as a reference tool in previous literature [11,12,13].

In phase 1, positive and negative psychological experiences of survivors were noted during disease. Pervious literature stipulated that Lockdown and social isolation caused emotional and psychological distresses, especially for those who are more susceptible to stress. anxiety, depression, change in mood, increased temper, sleeplessness, post trauma, mood swing and emotional exhaustion have been revealed by a person who underwent the process of quarantine [14, 15].

During the pandemic, survivors have reported high levels of depression, anxiety, and stress, with about 64% experiencing prolonged mental health issues such as post-traumatic stress [16]. Similarly, Ebola patients experienced mild depression, grief, social relationship problems, and stress, with 20% needing therapeutic interventions [17]. Recent phenomenological study have identified several themes related to the psychological experiences of COVID-19 patients. Early in the illness, patients often exhibit a negative attitude towards accepting their condition and face stigma. As time progresses, denial often shifts to acceptance. Patients also experience fear related to the viral nature of the infection, challenges in adhering to quarantine measures, and concerns about infecting family members. Emotional disturbances, sleep issues, loss of appetite, and difficulties in psychological adjustment are common. Additionally, patients express gratitude towards medical staff and caregivers [6]. A phenomenological study in turkey on 34 covid survivors incorporate the psychological experiences and develop themes through thematic analysis related to these experiences. The imperative themes of this qualitative study were denial and adaptation, fear of death and transmission of disease in other family members, social isolation, feeling of hopelessness, feeling of guilt and social stigmatization and collapse of economy [18].

Further phenomenological research found that COVID-19 patients exhibited negative attitudes and emotional states regarding the disease, with 16% reporting intense death anxiety and 40% experiencing moderate death anxiety. Various coping strategies were employed to manage negative emotions: 66% of patients engaged in religious reflection, 64% communicated with family, 62% prayed, 34% listened to religious speeches and music, and 30% watched movies.

In phase2, Post-recovery and post-traumatic growth, nearly all participants reported increased belief in God, faith in human relationships, respect for healthcare workers, and appreciation for security personnel. A quarter noted a decrease in their belief in material wealth [6]. A qualitative study on covid survivors incorporate the protective factor and generated themes such as coping mechanism, family support, significance of life, meaning attribution and resilience. results indicated that after illness covid survivors support these themes and struggle to control their emotional and psychological distresses [18].

Interpersonal relationships also emerged as a key theme. In China, studies on school adaptation during COVID-19 indicated that positive interpersonal relationships facilitated social support and adaptation [19]. In a qualitative study.

Given the importance of observing and practicing preventive health behaviors, this study aims to explore psychological experiences during and after COVID-19 in Pakistan. While extensive research has been conducted in Western contexts [20], there is a lack of studies addressing these issues in Eastern cultures like Pakistan. A recent study in India revealed strong impacts on participants’ lives, including uncertainty about treatment, psychological distress (depression and stress), fear, financial difficulties, discrimination, stigma, and loneliness [21]. The rationale for this study emphasizes the importance of exploring these variables within Eastern contexts, acknowledging the cultural distinctions in belief systems, societal priorities, and lifestyles that shape psychological experiences. The primary aim is to examine the psychological impact of COVID-19 in Pakistan, filling the gaps in existing research on Eastern cultures. As a collectivistic society with unique belief systems, Pakistan faced significant mental health challenges and disruptions to social relationships due to the extensive lockdown measures. In quarantine, people stay at home and under psychological and physical pressure experience self-isolation which creates fear, stress, and death anxiety. The research aims to provide a comprehensive understanding of these experiences during and after recovery from the infection.

Methods

Study design

This research employed a qualitative research design. Participants were selected using a purposive sampling technique, and data were collected through semi-structured interviews featuring open-ended questions.

Sample description

Thirteen COVID-19 survivors participated in the semi-structured interviews, all of whom provided their consent. The semi-interviews were conducted according to the guidelines of semi-structured interview by Bearman, 2019 [22]. The interview protocol has been prepared according to the two phases (during disease, after recovery from covid) of covid-19. five questions were asked from patients, how did you feel, when you know that you had covid? How did you feel, when you were admitted to the hospital as a patient? How has covid-19 affected your social and family life? in what way has the disease changed your views about life and the world. Have you noticed any changes in yourself after recovery? Participants ranged in age from 22 to 62 years. Interviews were conducted exclusively with symptomatic (fever, difficulty in breathing, congestion, loss of taste and smell, cough and body aches) and diagnosed. Those individuals who have a positive PCR covid test were included; asymptomatic and undiagnosed individuals were excluded. Out Of the 13 participants, 6 were male (46%) and 7 were female (54%). after recovery, only those patients were included in the study after 1or 2 months of recovery. Among the participants, 5 reported severe symptoms, with only 1 being female. Other 5 participants experienced moderate symptoms, including 3 females and 2 males. The remaining 3 participants had mild symptoms (Table 1).

Table 1 Details about the respondents (n = 13)

Procedure

The COVID-19 survivors who participated in the study were committed to sharing their experiences but were particularly concerned about maintaining their confidentiality. To address this, it was assured that all personal information would remain confidential and not be disclosed to anyone.

Data were gathered from 13 COVID-19 survivors through semi-structured interviews consisting of open-ended questions. Of these, 11 interviews were conducted face-to-face, while 2 were conducted virtually via WhatsApp video call. All interviews were recorded with the participants’ consent.

The semi-structured interviews comprised four primary questions: (1) Personal history of the patient, (2) Initial feelings upon discovering they had COVID-19, (3) Severity of symptoms (mild, moderate, or severe) and Feelings associated with the development of breathing problems, (4) Feelings experienced after recovery. Additional questions were posed based on the participants’ personal experiences or to gain further clarity on their responses. For example, (a) Many participants expressed a strong attachment to God; questions explored whether their belief in God intensified due to the illness; (b) Participants were asked if they felt uncertain about their future due to media-induced fear and hype; (c) The impact of optimism or pessimism regarding recovery was also explored.

Most interviews lasted approximately 30–40 min. Interviews were conducted after the participants had recovered from COVID-19. Specifically, 2 interviews were conducted within one month of recovery, while the remaining 11 were conducted after 2 months. Out of the 13 participants, 3 were referred for COVID-19 testing by medical practitioners, whereas 10 sought testing independently upon experiencing symptoms. The interviews continued until responses reached a point of saturation, at which no further interviews were deemed necessary.

Data analysis

Interpretive Phenomenological Analysis (IPA) was employed to analyze the results [23]. IPA facilitates an in-depth exploration of individuals’ psychological and social concerns, allowing for a nuanced understanding of their lived experiences.

The analysis began with transcribing the audio-recorded interviews verbatim. These transcripts were then read multiple times by the second and third authors to familiarize themselves with the data. Participants who experienced only mild symptoms reported no significant behavioral or psychological changes and did not exhibit prolonged effects of the disease. Consequently, the focus of the analysis was on those with moderate to severe symptoms, as these individuals experienced more substantial psychological stress.

Using IPA, initial codes were developed from the transcribed data and grouped into preliminary themes. These themes were refined into emergent themes following the guidelines outlined by Smith et al. [23]. The interviews were reviewed repeatedly to capture participants’ emotions and thoughts accurately. Statements with similar core meanings were identified, and codes were established for these statements, which were then organized into specific subthemes.

The analysis involved two researchers who established the coding instructions. These codes were reviewed and confirmed by other researchers to ensure accuracy. Disagreements regarding themes were resolved through consensus among the researchers, with the final coding reflecting a high level of agreement. The credibility of the research was enhanced by the comprehensive data collection and analysis processes. Coders became thoroughly familiar with the data, reading responses multiple times to ensure accurate coding. Direct quotes from participants were used to elucidate results, enhancing the transferability of the findings.

A coder not involved in the research process verified the themes, contributing to the study’s dependability. Confirmability was achieved through the agreement of all three coders on the themes. All coders reviewed the verbatim responses and confirmed the findings collaboratively. Unlike some other qualitative approaches, IPA does not typically quantify or formally assess reliability.

Limitations

The study’s qualitative approach involved a limited sample size, which might affect the generalizability of the results. Additionally, potential research biases may have influenced the coding and development of themes. As all participants belonged to the same ethnic and religious group, their coping strategies and psychological experiences may differ from those of individuals in other ethnic or cultural groups. A significant limitation of this study is that the experiences described are specific to a pandemic context and may not be directly applicable to other types of natural disasters. The present study helps the psychologist in the assessment of survivors of pandemic situation and design the therapeutic interventions to reduce the negative psychological experiences such stress, depression and anxiety. The study supports the effectiveness of these techniques in alleviating the fear and distress associated with the disease. For psychologists and counselors, understanding these emotional shifts can enhance their approach to supporting patients through both the acute and recovery phases of COVID-19, ultimately aiding in better management of their psychological well-being. The results of present study support the future researchers to identify the psychological experiences of survivors in the pandemic situation. It would also help to develop measurement tool to assess the psychological experiences in pandemic situation in future.

Ethical considerations

Informed consent was obtained from each participant prior to the interview. Participants were assured that their data would be kept confidential and used solely for research purposes. They were also informed that they could withdraw from the study at any time if they wished. The study adhered to APA ethical guidelines throughout.

Results

Table 2 presents the main themes and sub-themes about the patients’ experiences during the disease.

Table 2 Main themes and sub-themes of psychological experiences during the disease process

There are the following themes of the study, which are extracted from the verbatim of the participants. These verbatim helpful to identify the main and sub-themes of the study.

Denial

Feelings of rejection to accept the reality especially negative behavior. This theme explains the failure to accept a difficult reality. It was difficult for the participants to accept the existence of COVID-19 infection or the fact of them being infected with this disease. Examples of responses of participants are as follows;

I didn’t even know that I had corona. I even denied the existence of COVID-19 so it was very shocking for me.

Uncertainty toward disease

Vaccines for COVID-19 are not available yet and health professionals are unsure about the treatment of the disease which is why I feel more depressed and worried about my health condition. This situation is very uncertain. I thought that I couldn’t recover but when I did, I still felt stressed and depressed.

Psychological distress

A negative emotional state in which an individual fails to think rationally about their abilities and cannot cope with stressors or maintain healthy social relations.

Depression

Patients reported different symptoms of depression including lack of interest, insomnia, appetite loss, and feelings of loneliness and grief.

My sense of taste and smell disappeared which made me very anxious and I lost all my interest in daily life activities. I also have a disturbed sleep and loss of appetite. It was undoubtedly the hardest moment. I was very depressed during the disease. My physical condition was very weak. I felt exhausted all the time. I had no interest in daily life activities. My appetite was lost and I couldn’t sleep at night.

Stress

Feelings of uncertainty and unable to cope with the challenges and stressors is classified as stress. The patients were reported to be stressed throughout this process.

Throughout this crisis, I felt all the things drained my energy and I felt exhausted and stressed at times. Due to this pressure, I was even unable to follow the recommended diet.

Perceived social stigma

According to a health perspective,negative relationship between an individual and a group of people who transmit any contagious disease like in covid-19 pandemic. Discriminate and labelled by other people due to a specific disease.

I wanted to communicate and interact with my family due to the feeling of uncertainty, but I felt that people were afraid and hesitant to come near me because of this lethal and contagious infection.

Loneliness

It is a state in which a person faces difficulty in contacting other people in certain situations and,a decline of social relationships (Quarantine period).

It was a very difficult time for me during the quarantine period, I desperately wished to get in touch with my family and talk to them. I, first time, felt that loneliness is torture and it is extremely challenging to get through it.

Exposure to infections

It is fear of transmitting the disease (covid-19) to others. (Especially caregivers). The examples from the participant’s response are:

I was really worried about infecting my husband and son with COVID, so I suggested they stay away from me.

I didn’t want my eldest son to get infected from COVID so I stopped him from coming near to me. It was hard but I had to do it for my family’s protection.

Restrictions

These include the boundaries related to the pandemic like maintaining social distancing with their loved ones, and staying at home as suggested by WHO to prevent the disease from spreading. I felt stressed thinking that I was contagious and could infect my family so I recommended my family members to wear masks and sanitizer the daily used things about three to four times a day.

Coping strategies

It is to try to cope with the stressors and minimize the fear and pressure under stressful circumstances. God is with me; I will get fine eventually. I asked my family to do charity.

Active coping

Positive feelings and efforts to fight the disease involve religious coping and faith in God.

I suffered from severe breathing problem but I have a belief that God won’t leave me alone in this difficult time.

Avoidant coping

It is the trying of an individual to escape from dealing with the pressures of this disease.

I was not very hopeful about recovery. I felt very uncertain and thought about being very near to death especially when I had a severe breathing problem and I had to shift on the ventilator. It was quite stressful

Post-traumatic growth

Table 3 presents experiences of patients after disease.

Table 3 Main themes and sub-themes of psychological experiences after recovery from COVID-19

It is a positive change or feeling in psychological experiences after any traumatic event or challenge that increases the high order functioning. Answering one of the questions,the participant replied,

Of course, I felt the difference. My whole thinking pattern has changed. I have now seen death from very near and I have felt the importance of health and of all blessings that we look upon during normal life.

Attachment to god

It is an emotional bonding and a strong relationship between God and the believer,it works like a gauge of protection and comfort.

God has helped me throughout the disease and recovery, and I feel that I have developed a special relationship with God. I have a firmer belief now that he will not leave me alone.

Acceptance of death

Is the process in which individuals recognize the truth and the reality of death and accept it with a positive meaning.

It was an uncertain condition and I was ready to accept death at any moment. Now that I have seen death from very near, I have come to know the true feeling of being separated from my loved ones.

Gratitude towards god

It is feelings of appreciation and thankfulness toward God. Acknowledgement of blessings of God.

As Allah helped me throughout the infection, I now feel like I am more near to God and I am very thankful to him for giving me a new life. It was just like a miracle to recover and leave the deathbed, I cannot thank him enough for the courage to fight this disease and for life and all his blessings.

Trust in interpersonal relationships

This means positive feelings toward their close relationships and increased family bonding. Spent quality time with the family.

Family is very important to me and I was treated at home, so I needed my family all the time. It was their love for me and support that gave me a new life.

Gratitude towards people

Feelings of appreciation and thankfulness toward other people like medical staff, family members, and friends.

I am very thankful to all the health professionals who treated me when I was suffering from this contagious disease and I am equally thankful to my friends and families for supporting me.

Significance of life positive feelings

About the importance and worth of life.

I now know the importance of this life that we always take for granted. I have discovered the worth of a healthy life and all the blessings. Each moment of life has a different meaning and each day is important.

Delayed resilience slows the recovery process after any traumatic event

I didn’t have any hope of recovery and I felt extremely depressed while suffering from the disease. I felt weaker against this disease. Even after recovery. I couldn’t sleep properly.

Recovery of insomnia

To gain the optimum level of comfortable sleep.

Even after one and a half months of recovery, I used to feel during sleep that my breathing had stopped and at this thought, I used to wake up and then was unable to sleep for all night. It eventually got better after two months of recovery.

Post-covid psychological distress reduction

In frequencies of depression and stress,

Alhamdulillah now I feel better but still I am feeling exhausted and don’t want to do anything maybe I can’t do that. at night I feel that my breathing stops and can’t sleep properly. life is uncertain because I saw death very near to me when I was on a ventilator I am worried about my children and family.

Psychological experiences before and after the disease have been shown in Figs. 1 and 2.

Fig. 1

Flowchart of psychological experiences during the disease

Fig. 2

Flow chart of psychological experiences after the disease

Discussion

This study aimed to explore the psychological experiences of survivors of COVID-19. Data was gathered through semi-structured interviews with open-ended questions, allowing participants to provide detailed responses. The data, which was descriptive, was analyzed to develop themes. These themes, identified in this qualitative analysis, have been highlighted in previous surveys, media reports, and research studies. Throughout this challenging period, patients faced not only physical ailments but also severe psychological impacts [24, 25]. Early in the infection and during treatment, patients commonly experienced denial and struggled to accept their condition. Another prominent theme was social stigma, characterized by negative interactions and a decline in social relationships due to the contagious nature of the infection. Similar findings were reported in other studies, which noted fear, denial, and social stigma during the early stages of infection. Given the viral nature of COVID-19, it was challenging for patients to avoid contact with loved ones and remain isolated [6].

Psychological distress emerged as a major theme, with patients showing symptoms of depression and stress during treatment. Studies have shown that COVID-19 patients experienced more psychological distress compared to other patients undergoing treatment. For example, research from China reported that 28% of COVID-19 patients experienced depression and 34% experienced anxiety during quarantine and treatment [26]. Additionally, 30% of patients continued to experience depression even after recovering from the illness [27].

A study conducted in Switzerland examined various fears during and after lockdown across different age groups. The findings indicated different types of fear, with young individuals primarily concerned about job security during the lockdown, while elderly individuals experienced significant hopelessness post-lockdown [28]. Furthermore, elderly patients with chronic conditions faced challenges with online or remote physical examinations, which adversely affected both their physical and mental health [20].

Death anxiety was another significant theme identified in the analysis. Meng Xu et al. previously reported the prevalence of anxiety and depression among COVID-19 patients [29]. Death anxiety was found to be a critical factor contributing to a wide range of anxiety disorders. Other studies highlighted that older adult experienced more severe death anxiety during the pandemic [30, 31]. The high levels of anxiety and depression observed in COVID-19 patients were linked to increased death anxiety [32,33,34,35]. The contagious nature of the disease also raised concerns about the risk of infecting family members or caregivers. Recent research found that nurses working with COVID-19 patients feared both contracting the virus themselves and exposing their loved ones [36].

Coping strategies were a major theme, with active coping strategies proving to be effective for managing the crisis. A cross-sectional study in Pakistan found that spiritual or religious coping was particularly helpful in reducing stress and anxiety [37]. Conversely, avoidant coping strategies were associated with higher psychological distress and lower well-being [38].

The second part of the analysis focused on psychological experiences after recovery from COVID-19. The theme of post-traumatic growth was prevalent among participants, reflecting positive psychological development following the trauma. Sub-themes related to this growth included attachment to God, gratitude towards God, self-gratitude, acceptance of death, trust in interpersonal relationships, and an appreciation of life. The UK’s National Institute for Health and Care Excellence has noted that individuals exposed to traumatic events are at high risk for developing mental health problems. However, these distressing experiences often lead to meaningful personal narratives and positive behavioral changes, as observed in various traumatic incidents in the UK [39]. Additionally, Sahoo et al. reported that COVID-19 survivors expressed increased gratitude and respect for healthcare providers and a stronger faith in God. They also made efforts to maintain social connections with family members. Another theme identified was delayed resilience, which included sub-themes of recovery from disrupted sleep and post-COVID psychological health. Research on mass fatalities during the outbreak in New York indicated that COVID-19 patients experienced significant psychological distress and had a slow recovery process [40]. Further studies on COVID-19 patients in China during hospitalization revealed that, despite initial negative emotions, survivors experienced positive changes such as increased gratitude, improved family time, and a greater appreciation for life [41].

The findings indicate that patients initially experienced predominantly negative emotions during the early stages of the disease. However, post-recovery, they reported positive changes, including increased gratitude, a greater appreciation for family time, a renewed sense of life, and bravery. These positive transformations are associated with psychological growth in the patients [42].

Conclusions

This study, which focused on COVID-19 survivors, highlights several important clinical implications. The findings demonstrate that during the early stages of the illness, patients predominantly experienced negative emotions, such as denial, uncertainty toward disease, loneliness, psychological distress, social stigma, death anxiety, restrictions and exposure to infection. However, as they progressed through recovery, these emotions gradually evolved, leading to a mix of positive and negative mental states. After recovery, patients generally reported reflections that are more positive on their experiences and noted improvements in their outlook on life. After recovery, survivors experienced post-traumatic growth, attachment to God, acceptance of death, significance of life and interpersonal relationship, gratitude toward God and people and reduction in the psychological distress. These insights suggest that counseling and therapeutic interventions can be highly effective for individuals coping with the psychological impacts of COVID-19.