Coping with COVID-19 Isolation in Kerala, India: A Qualitative Analysis

ABSTRACT

COVID-19 has had a negative impact on all areas of human life. Populations both directly and indirectly affected faced similar challenges to a certain extent. This article explores the emergent attitudes and healthcare practices of COVID-19-affected people during the period of their isolation after positive infection, following a qualitative research design. A total of ten participants from Malappuram District, Kerala State, India were selected for the study by the convenience sampling method. Semi-structured telephone interviews were conducted to understand their emergent attitudes and health care practices. The results show that the attitudes and vulnerabilities of the individual during quarantine, environmental factors, and access and availability of resources, are the individual and social factors leading to major psychological impacts on participants during COVID-19 quarantines. Coping strategies and healthcare practices, mental health related practices, social connectivity, socioeconomic status and social support are individual and social factors that helped participants to overcome negative psychological impacts.

Keywords: Emergent attitudes, Healthcare practices, COVID-19 survivors

INTRODUCTION

A pandemic refers to an epidemic affecting a large geographic area, such as several countries across the world, and affecting a large portion of the population. SARS-CoV-2, or COVID-19, started with a small outbreak but it spread as an epidemic through many countries, affected a large portion of the population and hence was declared a pandemic by the World Health Organization (WHO) on March 11, 2019 (Knorr et al., 2020; World Health Organization, 2020b). In December 2019, the first human case of COVID-19 was reported in Wuhan, China. The genomic structure of the virus showed that it had a natural animal origin. If it were constructed in a laboratory setting, the genomic structure would likely be a mix of known elements (World Health Organization, 2020a). This article focuses on Kerala State, where the first case of COVID-19 in India was registered on 30 January 2020, one month after the first positive case was reported in China. India reported six active cases in the first week of March, three of which were in Kerala (Ranjan, 2020). In Kerala, the population is over 35 million and 4,189 cases of COVID-19 were registered by 30 June 2020 with 23 deaths with an impressive recovery rate of 51.7 percent (World Health Organization, 2020c). The fear of getting infected by COVID-19 is very prevalent in the general population (Bavel et al., 2020).

PSYCHOLOGICAL IMPACT OF COVID-19

Anxiety and depressive symptoms are commonly observed among people who diagnose positive for COVID-19, especially among those who were hospitalized early in the pandemic (Brooks et al., 2020). Reasons include worries about their own safety or others’ health, requirements for physical isolation (which may lead to social isolation), the risk of death, concerns about infecting others and concerns about leaving family members who might need treatment. The effects on people who recover from COVID-19 infection include immediate psychological that may also be long-lasting. Survivors of previous infectious disease outbreaks such as the first Severe Acute Respiratory Syndrome and the Middle East Respiratory Syndrome and other coronaviruses have been diagnosed with behavioural and attitudinal psychological reactions of fear, paranoia, panic, anxiety, and mental health disorders (Olufadewa et al., 2020).

Special stressors of COVID-19 include the fear of becoming sick and dying, fear of socializing excluded/in isolation, loss of life and loss of loved ones, being alone, feelings of helplessness, boredom, and loneliness (Reynolds & Leen et al., 2020). It is difficult for all individuals to adapt to shocks like these, not to mention handling the fear of catching the virus and worrying about those close to them who are especially vulnerable. These factors can be especially frustrating for people with mental health problems.

Fortunately, there are many things one can do to take care of one’s own mental wellbeing and to assist those who may need some additional support and care, such as reducing the consumption of disease-related news. Checking for the latest information once or twice a day will be better for those kinds of people. It will help them to reduce the stress (World Health Organization, 2022).

Sun et al. conducted a study to explore the psychology of COVID-19 patients during hospitalization. They found five themes related to psychological experience during hospitalization. From the study, it is clear that COVID-19 patients gradually changed their attitude toward the disease and displayed emotional responses depending on the stage of the disease. Negative emotions were high during the early stages but gradually changed to a mix of positive and negative emotions. Providing active guidance of psychological development may promote the physical and mental recovery of COVID-19 patients.

Being less resilient to social threats like pandemics may increase the risk of developing psychiatric conditions. Feelings of hope, optimism and social protection can improve coping abilities. They also enhance resilience and individual abilities to social threats (Serafini et al., 2020). Social contact is very important to maintain one’s mental health. Social contact and support reduce stress, depression, anxiety, isolation and improve self-esteem, wellbeing, and quality of life. Due to the widespread spread of the coronavirus disease, many health and government authorities tried to restrict physical contact and social proximity to prevent the infection from spreading.

The COVID-19 pandemic is also very relevant to the theory of personality since the threat was real, vivid, personally important, and ambiguous. The anticipation of consequences on life, health, and property from the pandemic and lockdown may have increased the impact of personality differences or characteristic trends in what people feel, think, want, do, and value, both good and bad. Subsequent uncertainty about the period of social distancing policies, the social stress of a severe financial crisis, and various disruptive factors can also intensify personality differences in outcome effects through risk actions, coping, needs and resources.

Studies describe the various outcomes that personality traits predict and can help to narrow the possible mechanisms by which traits operate (Jeronimus, 2020).Olufadewa et al. conducted a qualitative study to find out the physiological and psychological experience of COVID-19 patients during treatment ant and the quality of the care system in recovery processes (2020). They found that many participants had poor mental health experiences such as fear, anxiety, shame and concern about their recovery. Few participants had favorable mental health effects, such as a sense of support from family members and trusted friends. Many participants were happy with the quality of care at health centers, while some faced early difficulties in getting checked. It is stressful to be separated from loved ones and from society. In the present study, a problem faced by those who suffered from COVID -19 is identified as psychological distress. What factors help these people to overcome the situation? The article identifies protective factors which can be helpful to those who are isolated or alone because of any other disaster—not limited just to a pandemic. This research article’s objectives are to observe the health care practices among participants during quarantine periods associated with COVID-19 and to observe emerging attitudes among participants during quarantine periods associated with COVID-19. 

METHOD

A qualitative research design guided this study. A semi-structured interview schedule was prepared to gather more information related to the attitudes and health care practices during quarantine periods of patients who recovered from COVID-19. Our ‘Interview Schedule for Attitude and Practices during COVID- 19’ consisted of 12 items. A total of ten participants from Malappuram District, Kerala State, India were selected for the study by the convenience sampling method. Semi-structured telephone interviews were conducted to understand their emergent attitudes and health care practices. Probing questions and prompts were used to gather in-depth details of any imprecise answers. Each interview concluded in less than 30 minutes and the majority completed their interview within the 20—30 minutes range. All interviews were audio-recorded, in addition to that, the researcher noted down the specific and important details for each participant (table 1).

Table 1 

Summary of Personal Details of Participants

Verbatim transcriptions of audio recordings were made, shared and specific details were coded. Different codes were generated from the conversations with the ten participants. Codes like boredom, uncertainty, discrimination, sleep disturbances, loneliness, support from family, friends, and doctors, anxiety, etc. were noted. The coded data were analyzed based on the process of thematic network analysis. This involves extracting basic, organizing, and global themes from the text and then describing these themes as web-type maps of the relationship between each of them. The themes are arranged on the basis of similarities (Attride-Stirling, 2001, p. 390).

The inclusion criteria for participants were:

• Those who contracted and recovered from COVID-19.
• Those who completed seven days of quarantine after the treatment.

The exclusion criteria were:

• Those currently undergoing treatment for COVID-19.
• Those currently undergoing quarantine after the treatment.
• Those who did not undergo quarantine after treatment.

RESULTS AND DISCUSSION

From the analysis of the transcribed data, many codes were obtained. Based on the obtained codes, thematic network analysis was used to organize themes. Thematic network analysis involves extracting basic, organizing, and global themes from the text and then describing these themes as web-type maps of the relationship between each of them. Basic themes are of the lowest order and contain a simple concept characteristic of the text. Organizing themes are clusters of basic themes. Similar kinds of basic themes make up a cluster and form an organizing theme. Global themes are a cluster of organizing themes. The thematic network analysis is carried out by coding and cutting the segments out of the text. Themes are arranged on the basis of similarities. For better comprehension, each network is in sequential order. The main theme pattern is obtained by sequencing. The deduction made in the summary provides more information on the themes and their theoretical underpinnings (Attride-Stirling, 2001, p. 390).

In the present study, the researchers obtained two organizing themes for each of the two global themes. Basic themes were generated from the codes obtained from the transcribed conversations with participants. By analyzing the interviews common trends could be understood. Researchers drew inferences based on the conversations. Thematic network analysis has an organized structure which leads to a specific point of conclusion.

Table 2 

Codes and Themes for Determinants of Psychological Impact on Mental Health

BASIC THEME 1

Attitude and vulnerabilities of the individual during the period of quarantine. Quarantine is a restriction on one’s movement and freedom. But it is the most useful method to reduce the spread of disease. The most common reaction among the participants during quarantine was to feel negative emotions, like they have no control over their thoughts during that time.

It is common to feel negative emotions during quarantine. The main reason for this kind of emotion is separation and from beloved ones. Negative appraisal of the situation was present during and after the quarantine period as many misinterpreted the symptoms of other diseases as a reoccurrence of COVID-19. Factors affecting participants’ attitudes and thoughts included the thought of disease spreading to their family members.

As a result of the disease some people showed severe symptoms of COVID-19 such as fever, breathing difficulty, unproductive cough, body pain, and headache etc. Some people exhibited less severe symptoms such as throat pain, loss of smell and taste, etc. Some people were asymptomatic. This category of people has a high chance for spreading disease to others through contact. During the initial stages of the disease, people showed mild symptoms, though they had contact with others in their family, and with friends and colleagues. If a person becomes COVID-19 positive, they worry because of the chance for spread through the contact, and this affects the person’s mental health. The chance for spread makes participants develop fear, anxiety, and stress, but this finishes when people test negative.

Laymen have little knowledge about the symptoms, and seriousness of the disease. Poor knowledge and lack of previous experience of quarantine made the participants more vulnerable to develop negative emotions. As a result of this they developed an attitude of avoiding people to reduce the spread. After the quarantine, they restricted themselves to mingle with a small group of people. They started to avoid strangers and crowds as well as known persons. The fear of reoccurrence of the disease put restrictions on meeting others.

Being symptomatic also made them more vulnerable to psychological issues. As the severity of disease increased, the emotional instability and associated issues such as fear of death, anxiety, became  evident among the participants. Asymptomatic people also had the same psychological issues but these were not that much in evidence unlike the symptomatic participants.

Being symptomatic, having a lack of knowledge about the disease, and having fear of the reoccurrence of the disease are the major factors making participants more vulnerable to develop psychological issues. Thought of spreading the disease to family members helped participants develop an attitude of avoiding the crowd including known and unknown people.

“I am afraid only because of the chance of spreading disease to others who had contact with me, especially with my son, he is only four years old. If he is affected by the virus it will be very difficult to manage the situation. He can’t undergo quarantine and can’t live alone. So it will spread to all members in the family. This thought made me more uncomfortable during that time” (participant one, personal communication).

BASIC THEME 2

Environmental factors affect the individual during quarantine. Environmental factors are those which relate to one’s personal environment. This theme was developed based on the physical and psychological environmental factors that affect the person negatively during the period of quarantine. Thoughts and attitudes of the person are not the only factors leading to psychological distress. Personal environments also have a significant role in developing negative emotions. Being alone can lead to feeling of boredom and irritation. Most participants reported these problems during the post-quarantine period associated with the disease. Uncertainty about the future increased anxiety among the participants. The trait of having anxiety made some participants more vulnerable during the period. Financial crises due to the pandemic and family circumstances negatively affected the participants. Some participants were self-employed, had crises in their jobs, salary, and even experienced unemployment as a result of the pandemic; these are some environmental factors that made the participants more vulnerable to psychological distress and prone to anxiety. Crisis in meeting daily life needs, uncertainty about future events, unemployment, etc. made them more anxious during the period of research.

“University has declared the exam dates will be during my treatment period … At that time I was COVID-19 positive. I was tense because…. when will I complete the quarantine? At that time the post-COVID-19 quarantine was 14 days. The uncertainty of that time made me more stressful. And I was sleepless during those nights” (participant seven, personal communication).

ORGANIZING THEME 1

Individual determinants of psychological impacts on mental health. An organizing theme is developed through the combination of the basic themes. The basic themes obtained from the codes were drawn from the attitudes and vulnerabilities of participants during the research period, and environmental factors influencing the development of psychological distress and anxiety. These two themes are related to the affected person only. These factors can be controlled by the person themselves. But when being alone for a long time, all coping strategies will not be useful to everybody. From the present study it is clear that personal character has a role in coping with anxiety and psychological distress. Some of the participants showed symptoms of Post-Traumatic Stress Disorder (PTSD). Quarantine or social isolation has an enormous effect on people’s work and lives, and thus can have significant consequences for their health and wellbeing. These will lead the affected person as well as the general population to a higher level of stress and psychological issues, causing confusion, fear of infection and disease for themselves and their family members, and fear of economic loss.   

BASIC THEME 3

Social environment. Along with individual factors, social factors also cause psychological distress among survivors as well as the general population. The major social factor that made the experience more distressing to participants was discrimination and stigmatization from others. The labelling of people based on the disease was present during the initial months of COVID-19 in Kerala. Discriminating against COVID-19 survivors in social occasions, and in education and employment sectors, was experienced by some participants. But social support was received from others also.

The intensity of stigma associated with COVID-19 in the early stages of the pandemic was because it was a novel disease. There was uncertainty, anxiety, and fear among the general public. Unfortunately, these factors also fueled negative assumptions. Social factors causing anxiety and distress and discrimination from others went along with social media in playing a big role in making people fearful and anxious during that period. Social media is an easily accessible medium to view the latest news and updates by many people. Fake news and updates cause people to misinterpret the symptoms of other disorders as symptoms of COVID-19.  Sharing misleading information such as false treatment protocols and misleading symptoms was very common. This kind of information will be accepted by the layman and uneducated people. It causes more problems for them: for example, the fact that alcohol-based sanitizer prevents kills the virus on surfaces led people to drink alcohol to resist the virus. This kind of misleading and fake information affected quarantined people too. As a result, they themselves tested and treated the disease. Use of social media for social connectivity may be a protective factor to reduce the pressure of loneliness and isolation, but relying on its information can affect people’s mental health.

The proximity of life events such as marriage, educational admission, and job interviews can be considered stressors to induce adjustment issues during the period of quarantine. These throw into relief restrictions on the person’s freedom of mobility. Being under quarantine, some of the participants lost their chance for getting a job and one girl lost her opportunity to study in another state: “After being discharged … I reached my home … but the people near to my neighborhood called me Covid Lady” (participant five, personal communication).

BASIC THEME 4

Access and availability of resources. During the initial phase of the disease no vaccine or treatment protocol was found. As a result of this uncertainty, people panicked. During that time the death rate of COVID-19 patients in Kerala was around 20 people per day. But many countries including India were started to develop vaccines for the prevention of transmission. In the meantime doctors prescribed medicine for symptoms for severe patients and for minor cases they prescribed vitamin tablets.

As the number of cases increased in Kerala, the number of FLTCs (quarantines) also increased. But slowly less severe cases were allowed to be treated at home, strictly following quarantine periods under the supervision of health workers in respective areas. Being under quarantine in their home was less stressful than being institutionalized. At home, quarantined patients can talk with their family members, and there is no change in their environment of living. Restrictions on contact with family members were strictly maintained by the participants themselves to block the spread of disease to others in the house.

“I was under quarantine in the upstairs of my home… I could see my parents through the window… they gave me food up at the entry to the upstairs... I think it is better to be quarantined one’s own house, if there is the facilities...otherwise, isolation and separation can make a person fearful and anxious… even though, I have felt boredom and irritation because I can’t go outside” (participant ten, personal communication).

ORGANISING THEME 2

Social determinants of psychological impacts on mental health. Social factors related to the individual person included their environment and access to resources. While exploring the social factors leading to anxiety and psychological distress it was found that discrimination from others, labelling based on the disease, and the influence of fake news had a significant role. As part of the fear of spread, and consequences of the disease, forced quarantine may be the reason for people keeping distance from the COVID-19 survivors. These precautions made survivors feel guilty and stigmatized.

Being stuck under quarantine and unable to fulfil one’s responsibilities made people irritable and restless. Most participants worried about their responsibilities and future events. During quarantine participants relied on updates through social media. Sharing fake news related to treatment and symptoms affected their mental health negatively. Based on the news reports patients have the chance to experiment with treatment methods to cure the disease. During the initial phase of the disease, the WHO declared there was no proper medicine for the disease and symptoms could be controlled by the appropriate medicines, but people followed fake news and experimented themselves.

GLOBAL THEME 1

Determinants of psychological impacts on mental health during quarantine. Each COVID-19 survivors have their own story and experiences of days under quarantine. Many studies account that the isolation, separation, and restrictions affected people’s mental health. Loneliness, severe disease symptoms, boredom, irritation, and uncertainty can increase the anxiety of COVID-19 patients. Other than personal feelings and experiences, social factors also play a major role. Lack of treatment, labelling and discrimination based on the disease, the influence of fake news etc., also caused stress among participants. The results obtained from our Impact of Event Scale-Revised showed a majority of the participants scored high on avoidance and intrusive thoughts. As a result of the quarantine, some participants showed symptoms of PTSD.  Participants blamed themselves as being careless and the impact of the disease made them sleepless during night. Nightmares of reoccurrence of the disease was common among them.

Table 3 

Codes and Themes for Determinants of Overcoming the Impact on Mental Health

BASIC THEME 1

Coping strategies and healthcare practices. Emotional instability, increased anxiety, and distress are common in patients undergoing isolation and quarantine. Balancing mental health during this period is a hazardous task. Some people considered the disease to be traumatic and needed more time and professional help to recover from its impact. Learning to cope with the situation will improve mental health and make the person more resilient. During quarantine some participants worked from home and some prepared for exams, engaging in tasks to be productive. They rarely felt boredom, loneliness and irritation.

Knowledge and education has a role in coping with psychological distress. Educated people have understand the consequences of the disease and they can manage because of this knowledge. Some participants had risk perception skills such that they were aware of the disease’s seriousness and they were willing to complete the quarantine for the prescribed days. Asymptomatic patients may feel negative and positive emotions. The person is labelled as a COVID-19 patient and quarantine and isolation can cause negative emotions. On the other hand, being asymptomatic they do not face any health related issues, so they may feel lucky and healthy.

Health care practices during the quarantine period was common among patients and in the general population. Many people use folk remedies to prevent disease. Physical exercise was continuously done by one participant to stay healthy. Many of the participants rely on folk remedies such as boiled water with lemon and ginger, inhaling vapors of water boiled with turmeric etc. and most participants took care of their physical health than their mental health in some way.

“During the period of my quarantine the exam dates were announced … I was upset at that time … because I thought I can’t attend the exam ... I was not informed by the health workers when the quarantine ends ... Though I started to prepare for the exams ... I got more time to prepare for the exams” (participant three, personal communication).

BASIC THEME 2

Mental health related practices during quarantine. For maintaining mental health, patients connected with their close circle of people. Hobbies like reading, watching movies, and listening to music were activities done to entertain themselves. Health is a vital part of coping with stress. Positive coping strategies include yoga, swimming, light exercise, and other types of everyday physical activity. It helps to release endorphins and controls the circulatory process in the body. “I consider this as time to take care of ourselves ... I focused on my health, ate healthy food, slept a lot, and exercised every day … within those days I read some novels” (participant four, personal communication).

ORGANIZING THEME 1

Individual determinants to overcome psychological distress. Many of the participants reported that they were mentally worn down during the period of quarantine, but some of them were not mentally affected by the disease. This difference in opinion proposes the question: is there any individual difference in overcoming distress? Based on the obtained themes and codes the answer is clear that there exists an individual difference in coping. Coping studies have shown that there is a strong neurobiological correlation among stress and adjustment. According to Freud, escape, denial, and restraint are neurotic defenses that absorb energy. Ignoring a crisis may help temporarily, but it is a good idea to consider the crisis and prepare. From conversations with participants, we learned some individual factors helped them face the challenge of the situation. They were: their resiliency, their approach to the disease, education and knowledge about the disease, doing activities for maintaining physical and mental health, their attitude towards the isolation period, etc.

BASIC THEME 3

Social connectivity. The term social connectivity refers to how connected people are, whether people hang out with friends and relatives, take an interest in various events or have a sense of community. People affected by COVID-19 used social media platforms like WhatsApp, Facebook, etc. to stay connected with social groups, including family, friends, co-students and colleagues, and social groups. The participants reported that the use of social media was high during the period of quarantine. Studies show that human connection or social connectivity has a role in supporting person’s mental and physical health. Having strong social connectivity helps patients be happy for a longer time, to be healthy and have a lower level of anxiety. Social ties help to decrease stress during traumatic events in life. It improves their optimism, resilience and wellbeing. 

BASIC THEME 4

Socioeconomic status and social support. One study revealed that people experienced lower wellbeing during the pandemic compared to the period before the pandemic (Wanberg et al., 2020). Educated people had more decreased wellbeing than the uneducated group. The highest income group experienced the lowest life satisfaction. Support from family, friends, health workers, the government and authorities were factors assisting wellbeing. There existed some stigma about COVID-19 patients, but many people supported and helped the patients because of their relation and closeness to them: “After the quarantine I rejoined my job and my colleagues were very supportive, they are not afraid and do not hesitate sit near me and share food with me” (participant nine, personal communication).

ORGANIZING THEME 2

Social determinants for overcoming psychological distress. Being a social animal, humans benefit from being connected with others. Distress due to quarantine can be overcome through social relations. Individual ways of relieving distress are also useful. Even so, everybody needs social support and connections in some way. In the present study all participants were socially active with many friends and, moreover, some of the participants received a high score on the extraversion trait. This indicates that social gatherings and contacts are a big part of their life. Being isolated from society makes those people despair and become mentally weak. To overcome anxiety, fear, distress, uncertainty, etc. people rely on others, their family members, friends, relatives or colleagues. Letting out their worries to others makes patients more comfortable. Many of the participants liked to seek help from others. But under quarantine restrictions, participants only contacted their social groups through social media. Using the media was used for entertainment also. Social connectivity and social support had a major role in overcoming the impact of the disease for many of the participants. 

GLOBAL THEME 2

Determinants for overcoming psychological distress. The outbreak of COVID-19 has had a great deal of psychological impact on people, needing the attention of authorities to deal with the situation. Research records shows that social support has an important role in physical and mental health. It improves immunity, decreases anxiety, depression, and other chronic illness. Individual factors like personal attitude to disease, coping strategies, hobbies during quarantine, new health care practices, education, age, gender, financial stability, knowledge about the disease, family environment, lack of vulnerabilities, etc. all helps people to be resilient to such a stressful event. 

MAJOR FINDINGS

The results from our thematic network analysis show two global themes: determinants of psychological impacts on mental health during quarantine and determinants for overcoming psychological distress. The former includes individual determinants such as the attitude and vulnerabilities of the individual during quarantine and environmental factors that affect the individual during quarantine. The vulnerabilities mentioned by participants were: being symptomatic, lack of knowledge about the seriousness and consequences of the disease, fear of contact with others or crowds and fear of reoccurrence of the disease. They were very afraid of spreading the disease to others especially to their family members. They avoided crowds, including known and unknown people. The environmental factors related included feelings of loneliness, uncertainty about the future life, boredom, financial and job-related stress, difficulty in meeting daily chores, family circumstances, and anxiety. Other determinants of psychological impacts on mental health during quarantine included the social environment of the person, such as being discriminated against and stigmatized, the unreliability of news spreading through social media, the occurrence of life events such as marriage, education, jobs etc. The access and availability of resources includes lack of specific treatments, protocols and medicine, being treated at home and being under home quarantine.

The second global theme obtained was determinants for overcoming psychological distress. This too has two dimensions: individual factors and social factors. Individual determinants include coping strategies and healthcare practices and mental health related practices during quarantine. Health care practices and coping strategies include physical activities, engaging with work and studies during quarantine, and being asymptomatic making participants more comfortable to face isolation. Knowledge about the disease is considered a protective factor for coping with the disease. Concentrating on entertainment and hobbies made participants more positive during quarantine and it helped them to improve their mental health. Social determinants for overcoming psychological distress included the social connectivity of the participants with others. Social support played a major role in decreasing fear and anxiety about the disease.

CONCLUSION

Both individual factors and social factors can contribute to psychological distress during periods of trauma and both factors can also act to decrease the psychological impact of a life threatening event. All participants felt negative emotions and like they had no control over their thoughts during their quarantines. The main reason was due to being separated from their loved ones. Poor knowledge and lack of previous experience of quarantine made participants more vulnerable to developing negative emotions. As a result of this they developed an attitude of avoiding people, to reduce the spread of the disease. After the quarantine, they restricted themselves to mingle with only a select group of people. They started avoiding strangers and crowds as well as people known to them. The fear of reoccurrence of the disease put restrictions on meeting others. 

Being symptomatic made them more vulnerable to psychological issues. As the severity of disease increased, the emotional instability and associated issues such as fear of death and anxiety were evident among participants. Being symptomatic, lack of knowledge about the disease, fear of reoccurrence of the disease were the major thoughts making participants more vulnerable to developing psychological issues. The thought of spreading the disease to family members made participants develop an attitude of avoiding crowds including known and unknown people.

Health care practices during the period were common among participants and in the general population. Many people use folk remedies to prevent disease. Physical exercise was continuously done by one participant to be healthy all the time. Many of the participants relied on the folk remedies such as boiled water with lemon and ginger, inhaling the vapors of boiled water with turmeric etc. and most participants took care of their physical health more than their mental health.

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