Psychological Impact of the COVID-19 Pandemic on the Pakistani Population and Health Care Providers

The psychological impact of the COVID-19 pandemic in Pakistan was profoundly challenging, gravely affecting both the general public and healthcare providers. The troubling situation evolved from various interrelated factors as high illiteracy left people susceptible to quacks, clerics, conspiracy theories, and distrust of formal care. Concurrently, unemployment drove financial constraints and increased domestic violence risk in the lower socioeconomic class. Public attitude towards COVID-19 restriction faced backlash with frequent violations of isolation guidelines and attacks on law enforcement personnel. Moreover, psychological services did not receive enough attention from the general public as easy remedies promoted by questionable sources attracted more interest from the general public. These complicated factors added additional pressure on health services providers who were already bearing strains at the personal and professional level including the moral dilemma of saving critically ill patients, the potential of carrying infection to loved ones, and persistent fear of safety compounded by regular media reports of medical staff mortalities. Consequently, many healthcare providers restricted their services and some resigned from their positions due to stressors emanating from social confusion, lack of respect, and inadequate support for frontline workers.
Keywords: COVID-19, Psychological Impact, Healthcare Provider, Pakistani Population

The psychological crisis of the COVID-19 pandemic in Pakistan closely resembled that observed in various developed and underdeveloped countries. However, a notable difference was observed in how the Pakistani people responded to the coronavirus pandemic. Misinformation about the coronavirus swept through social networking sites and other information sources in Pakistan. People became involved in an upsurge of false information regardless of their expertise and background knowledge, except for authentic and relevant sources. Political figures, clerics, and quacks presented their ideas and theories with opposing contexts or incorporated scientific information according to their agendas. Some coronavirus treatments could be easily found on social media. Quick remedies for psychological issues offered by clerics and quacks were more easily accessible to people than masks or hand sanitizers. People would rather recite one holy verse thousands of times to overcome their anxiety or fear than listen to a mental health professional's advice.
The number of recitations of one verse could supposedly get them rid of lockdown or quarantine-related obsessions, depression, and other psychological issues. Hence, they didn't strive to seek mental health professional help for psychological first aid, stress management, or social support. By and large, this was the common attitude of ordinary people regarding the coronavirus. Social and religious gatherings continued to take place. In slum areas, children could be seen playing cricket, ignoring the government's appeal for a lockdown. The prevalent ignorance of the general population towards mental health issues resulted in a lack of mental health literacy¹.

Chances of Domestic Violence During the Lockdown in Pakistan
Pakistan is an underdeveloped country where a significant number of people live below the poverty line, particularly in rural areas and within patriarchal joint families. In low-income households, many men work on daily wages or in minor jobs. During the pandemic, they were deprived of their daily wage jobs and confined by lockdowns in Pakistan. This led to increased frustration and stress due to job loss and financial constraints, which often manifested in abusive behavior towards spouses or children.
Several previous studies have indicated that abusers can become more violent and even resort to homicide during times of crisis, such as job loss and major financial difficulties².
Although there were no reports of domestic abuse specifically during COVID-19 in Pakistan, it can be speculated that, given Pakistan's gender inequality index ranking of 130 and the global gender gap index ranking of 143, which places it as the third most dangerous country for women in the world according to UN reports³, domestic abuse was likely prevalent. More than 70% of women in Pakistan are subjected to psychological, emotional, and physical violence, yet the majority of cases remain unreported. A recent study suggested that the prevalence rate of domestic violence in the rural population was 38%, while 59% of domestic violence victims had never reported abuse before COVID-19. Despite a global rise in domestic violence, it did not receive significant media coverage in Pakistan. The number of domestic abuse cases during the pandemic was likely higher than reported, but these cases were not widely covered by mainstream media.

The Coronavirus Patient’s Dilemma in Pakistan.
The attitude of coronavirus patients became another pressing issue for the government and related professionals. Many patients viewed quarantine facilities as imprisonment and often attempted to escape. For them, confinement was hard to accept as part of their treatment, and they struggled to manage psychological crises during quarantine. Most patients complained about not receiving any treatment in these facilities. They found it difficult to understand the nature of their viral infection and the rationale behind the restrictions. The state of mistrust among the public was exacerbated by reported attacks on police and other government officials by COVID-19 patients. Hundreds of people who were in hotspots went missing from government records. The situation worsened as different sects of religious fanatics engaged in a blame game, accusing each other of being responsible for the spread of the COVID-19. Several factors contributed to this situation, including patients' mistrust of authorities, the police's humiliating attitude, lack of support from clergy, and general illiteracy⁴.

Delivery of Mental Health Services during COVID-19 in Pakistan
Mental health professionals worked along with health professionals in different government and private settings to provide their services to people. For mental health professionals, it was not solely a battle against the coronavirus health emergency or its psychological effects; rather, it was a contest against the mental hotchpotch and the tangled state of people's minds. People approached health professionals and tried to validate all false perceptions that had no grounds. For instance, so-called scholars in the country propagated multiple conspiracy theories, which seemed more convincing to people than scientific explanations. However, mental health institutes initiated on-call consultations for people with coronavirus-related psychological issues, albeit the number of available mental health professionals was not enough for such a large population of Pakistan⁵.

Psychological Crises & Challenges for Health Care Professionals
The more intense psychological stress was seen in health professionals working during COVID-19 and in quarantine facilities as they experienced PTSD and moral injury because they had to grin and bear it. The barely limited number of health professionals had ever tended to critical patients in life-and-death situations like COVID-19 patients, where their single decision would determine the fate of the patient's life. For instance, facing ventilator shortages in Italy constituted a moral dilemma for medical staff, as they were forced to make difficult choices between extremely ill coronavirus patients. These professionals would carry the impact of such intense life experiences in the form of PTSD symptoms for many years. Similarly, professionals working in quarantine facilities encountered a wide range of psychological issues including fatigue, lack of support from others and anxiety while attending to delirious patients. These problems further led to anger, insomnia, poor concentration, indecisiveness, and a decline in work performance⁶.
Moreover, the fear of being infected or becoming a carrier caused devastating psychological consequences for health professionals. For example, in two different reported cases, COVID-19-infected nurses in Italy committed suicide out of fear that they might transmit the virus to others. It did not end there; quarantined staff and health professionals were stigmatized by people's indifferent and cautious attitudes towards them due to the fear of contracting the coronavirus. However, the psychological resilience of Pakistani health professionals against coronavirus disease (COVID-19) was not tested as profoundly as it was in highly infected countries in Europe and the USA. Although emergencies of such magnitude had not previously occurred, the psychological state of Pakistani health professionals was already quite strained. They had to contend with additional challenges while serving patients. Doctors strongly believed that the number of COVID-19 cases was far higher than those identified in government testing centers; many patients with COVID-19 were categorized as general patients, posing a contagion risk. Several general physicians and emergency doctors reported suspicious deaths of patients who exhibited symptoms indistinguishable from those of COVID-19 before their deaths. Such incidents were frequently discussed among the public and reported in the media, which aggravated health professionals' frustration, stress levels, and trauma.
Moreover, several other issues compounded the difficulties for health professionals, including a lack of PPE, limited testing facilities, a shortage of ventilators, the absence of isolation wards in every hospital, confused administrative decision-making, and delayed responses from government institutions. Additionally, the misleading attitudes of clerics and political figures in shaping public opinion diluted efforts on health emergency precaution initiatives. This intensified the situation for the medical community, leading to conflicts with authorities following the detection of coronavirus cases and the deaths of doctors, which eventually resulted in protests and the detention of doctors in one of the provincial capitals. The situation for health professionals became even more convoluted when illiterate individuals visited hospital OPDs, often with misinformation or misguided beliefs from various sources. Many people viewed the coronavirus as a curse from God that only affected non-believers. It was extremely challenging for these individuals to accept the infection disease model, understand the outbreak mechanism, and follow basic precautions to halt the spread of the infection. Healthcare professionals, on the one hand, had to manage pure medical emergencies, while on the other hand, they had to contend with peoples’ irrational beliefs about COVID-19. This misinformation and confusion were even more menacing when hundreds of patients attended in one day and showed neglectful behavior toward the medical advice provided. Despite all media campaigns, public awareness notices, and enforced lockdowns, people continued to display ignorant behaviors regarding infection control. This kind of attitude was commonly observed in DHQ and THQ hospitals. As a result, fear, desperation, trauma, and low morale were prevalent among health professionals, with many doctors and other professionals seriously considering quitting their jobs. Because they believed that their services and scarifies at up front did not earn support and respect from public and authorities.

1. Hayat K, Arshed M, Fiaz I, Afreen U, Khan FU, Khan TA, Kadirhaz M, Shukar S, Saeed A, Gill MR, Fang Y. Impact of COVID-19 on the mental health of healthcare workers: a cross-sectional study from Pakistan. Frontiers in public health. 2021 Apr 26; 9:603602. https://doi.org/10.3389/fpubh.2021.603602
2. Awad ME, Rumley JC, Vazquez JA, Devine JG. Perioperative considerations in urgent surgical care of suspected and confirmed COVID-19 orthopaedic patients: operating room protocols and recommendations in the current COVID-19 pandemic. JAAOS-Journal of the American Academy of Orthopaedic Surgeons 2020;28(11): 451-463. https://doi.org/10.5435/jaaos-d-20- 00227
3. Lopes N, Vernuccio F, Costantino C, Imburgia C, Gregoretti C, Salomone S, et al. An Italian guidance model for the management of suspected or confirmed COVID-19 patients in the primary care setting. Frontiers in Public Health 2020; 8:738. https://doi.org/10.3389%2Ffpubh.2020.572042
4. Habib M, Abbas M. Facing the threat of COVID-19 in Pakistan: a nation’s dilemma. Value in health regional issues. 2021; 24:90-5. https://doi.org/10.1016/j.vhri.2020.10.005
5. Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak. Asian journal of psychiatry. 2020; 51:102080. https://doi.org/10.1016%2Fj.ajp.2020.102080
6. Baloh J, Reisinger HS, Dukes K, da Silva JP, Salehi, HP, Ward M, et al. Healthcare workers’ strategies for doffing personal protective equipment. Clinical Infectious Diseases 2019;69(Supplement_3), S192- S198. https://doi.org/10.1093/cid/ciz613