Yao BIAN, Haobin YUAN, Wipada KUNAVIKTIKUL

1Faculty of Health Sciences and Sports, Macao Polytechnic University, Macao, China; 2School of Nursing, Panyapiwat Institute of Management, Nonthaburi, Thailand

ABSTRACT

The purpose of this review is to integrate the psychological experience of infected individuals during the pandemic.The spread of the pandemic has led to psychological and emotional impacts on patients.A qualitative synthesis is needed to identify, appraise, and integrate the available qualitative findings to provide an evidence for the development of interventions.A meta-aggregation approach was used to analyze studies published in English from January 2020 to August 2021.The JBI Qualitative Assessment and Review Instrument was used to assess the methodological quality of included studies.The ConQual system was used to establish the dependability and credibility in the synthesized findings.Six phenomenological studies and one narrative inquiry with an overall quality score of 70%-100% were included.The research findings from 87 participants in eligible studies were aggregated into three categories based on similarity of meaning.Two synthesized findings were generated and rated as moderate based on the ConQual score.The synthesized findings suggested that participants had psychological distress such as fear, anxiety, loneliness, and uncertainty, but they accepted the fact of being infected and tried to adjust themselves using some self-coping strategies, such as diverting attention from disease, seeking help from professional counselors, relying on religious beliefs,and participating in religious activities.They would like to learn more about infections and diseases and needed more informational support from health-care professionals.They were looking forward to recovery from the disease.

Keywords: COVID-19, meta-synthesis, pandemic, psychological experience, qualitative study

INTRODUCTION

Infectious disease is caused by pathogenic microorganisms,such as bacteria, viruses, parasites, or fungi which can spread directly or indirectly from one person to another.A pandemic is an infectious disease that crosses international borders and affects people worldwide, such as coronavirus disease-2019 (COVID-19).The spread and consequences of the COVID-19 have posed a threat to public health and a challenge to the responsiveness of the public health systems.[1]Public health measures are being implemented globally to suppress virus transmission and reduce mortality and morbidity caused by the infection.[2]The pandemic has had psychological and emotional impacts on infected individuals.Existing studies showed that the pandemic forced patients to stay in isolation wards away from their families, where they lived in fear and anxiety.[3,4]A survey of 6789 Spanish adults between April 22 and 26, 2020,showed that people experienced being overwhelmed or psychological distress (45.7%), symptoms on the depression spectrum (43.2%), uncertainty (77.5%), symptoms of anxiety and feelings of loneliness (35.1%), worry over suffering from a serious disease (67.9%), irritation or anger (47.4%),and fear of the death (75.5%).[5]Saidietal.[6]studied 103 infected individuals aged 16-90 years in the isolation ward of a hospital in Marrakech, Morocco, from March 13, 2020,to June 13, 2020, and reported that 36.89% and 23.30% of infected individuals had symptoms of anxiety or depression,respectively.An analysis of posttraumatic stress symptoms of 238 infected people in Northern Italy showed that 25.6% had mild symptoms, 11.3% had moderate symptoms, 5.9% had severe symptoms, and about one-fifth continued to have symptoms 4 months after discharge.[7]This underscores how mental health and appropriate interventions are still an important part of clinical care for infected and high-risk groups.

Qualitative research is conducted to understand people’s beliefs, experiences, attitudes, behaviors, and interactions in specific phenomena or situations.Qualitative studies focus on specific phenomena as situated in unique and particular experience of individuals.A literature review showed that several qualitative studies were conducted to explore the lives and survival experience of infected individuals.Meta-synthesis is a rigorous method of re-analyzing and integrating qualitative evidence that can generate insights beyond those found in a single study.It allows for an expansion of understanding of phenomena,confirmation of explanations, and the discovery of new explanations, thereby providing comprehensive interpretations.[8,9]Synthesizing studies across countries and cultural contexts can offer a greater understanding about the psychological experience of the infected population during the pandemic.The integration of qualitative findings is needed to provide evidence for the subsequent development of psychological interventions.The purpose of this study was to integrate the psychological experience of the infected individuals during the pandemic through qualitative evidence synthesis.

METHODS

Criteria for considering studies for this review

The PICoS tool was used to identify components of study inclusion through the evaluation of “Participant,”“Phenomena of interest,” “Context,” and “Study design.”The participants were individuals (aged over 18 years)who were infected with COVID-19.The phenomena were the psychological experience and feelings of the infected population during the pandemic.The experience included the voices and narratives of participants recorded in verbatim format.The analytical interpretations of the experience were conducted in the form of objective depictions.The context was accessing specialized health-care services in isolation wards of hospitals.This review considered the critical and interpretive studies that focused on qualitative data,including, but not limited to, designs such as phenomenology,ethnography, grounded theory, and narrative inquiry.The reporting was in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Version 2020).[10]

Search strategy

Two independent reviewers conducted comprehensive searches of relevant electronic databases and manual searches of relevant research bibliographies.Databases searched included the China National Knowledge Infrastructure,Wanfang Data, China Science and Technology Journal Database, CINAHL, PubMed, ScienceDirect, the Joanna Briggs Institute Library, and the Cochrane Library.The retrieval time was from January 2020 to August 2021.Qualitative studies were retrieved by combining subject headings and free words, and were not limited by language when using the search terms to search the database.The search terms were infect, pandemic, patient, psychological, experience,perception, feeling, qualitative research, qualitative study,narrative, and interview.In the case of any disagreement between the two reviewers, a third collaborator participated in the decision-making process.

Study selection and quality assessment

Following a comprehensive search, all identified citations were imported into EndNote X9 (Clarivate Analytics, PA,USA) for re-checking and deletion of duplicate studies.Reviewers initially screened the titles and abstracts for eligibility according to inclusion criteria, then read the full text and assessed the quality of the literature.The critical appraisal of each original study and its subsequent inclusion or exclusion can directly affect the quality of meta-synthesis.Two independent reviewers used the JBI Qualitative Assessment and Review Instrument (JBI-QARI) to assess the quality of the methodology of each eligible study.The JBI-QARI consists of 10 items, including research methodologies, philosophical bases,research purposes, data collection methods, data analysis methods, consistency of interpretation of results, source of conclusions, consideration of the influence of researchers on the research, the representativeness of participants, and ethical norms.For each item, the response is “yes” (if the criteria were met), “no” (if the criteria were not met), or“unclear” (if it was unclear whether the criteria were met).[11]Studies that met the criteria of Q1 to Q5, Q8, and Q10 were included in the review.Any differences of opinion between the reviewers were discussed, and a consensus was reached.

Data extraction and synthesis

Two independent reviewers extracted data from the included studies using the modified data extraction tool available in JBI SUMARI.[12]The extracted data included research designs, populations, interview methods, and main findings about psychological feelings or experience.The findings were assembled and categorized based on similarity of meaning.These categories were then integrated to generate comprehensive findings.

Assessing the dependability and credibility

Based on the suggestions of Munnetal.,[13]dependability and credibility are two elements considered by the methodological group to influence the confidence of qualitative synthesized findings.The ConQual score uses a four-level rating system (high, moderate, low, and very low).In the meta-aggregation, the resultant synthesis is directly related to the findings of each included study.Dependability is determined by analyzing methodological quality appraisal scores (questions 2, 3, 4, 6, and 7 in the JBI-QARI) to determine how study authors have met the specifications.Downgrading of dependability may occur when the five criteria are not met across the included studies.When four or five of the responses are “yes,” it is rated as “high.” If two to three of the responses are “yes,”the rating is downgraded from high to moderate.Zero to one “yes” response results in downgrading from high to low or moderate to very low.Furthermore, the credibility of the findings can be established by assessing the congruency between the authors’ interpretation and the supporting data.Credibility of the synthesized findings is determined by analyzing the levels of credibility applied during the data extraction stage.Each extracted finding is evaluated with a level of credibility based on the following ranks: (1)unequivocal (finding is accompanied by an explanation that is beyond reasonable doubt); (2) equivocal (finding is accompanied by an explanation that lacks a clear connection to it); and (3) unsupported (finding is not supported by the data).Downgrading for credibility may occur when not all included findings are considered unequivocal.For a mix of unequivocal/equivocal findings, the synthesized finding can be downgraded one level (from high to moderate).For equivocal findings, the synthesized finding can be downgraded two levels.For equivocal/unsupported findings,it can be downgraded three levels, and for unsupported findings, it can be downgraded four levels.[13]

RESULTS

Study inclusion

The primary search yielded a total of 325 studies.Of these studies, 60 duplicated articles were excluded using Endnote X9.Of the remaining 265 studies, 203 studies were excluded after reading of titles and abstracts, and then 46 additional studies were excluded after initial screening based on the inclusion criteria.Finally, 16 full-text articles were assessed for the quality of methodology.After critical appraisal,only 7 eligible studies[1,14-19]were included in the final analysis [Figure 1].

Figure 1: Preferred Reportng Items for Systematc Reviews and Meta-Analyses-P flow diagram of study selecton and inclusion process

Characteristics of included studies

The characteristics of included studies are shown in Table 1.

Table 1: Descriptions of the characteristics of included studies

Quality of methodology and dependability/credibility in synthesized findings

The overall quality of studies ranged from 70% (7 out of 10 questions answered “yes”) to 100% (10 out of 10 questions answered “yes”), with lower-scoring studies answering“no” on questions 6 and 7.The ranking of dependability was rated as moderate.The credibility of each synthesized finding was rated as moderate since a mix of unequivocal/equivocal findings were found.Two synthesized findings were generated and rated as moderate on the ConQual score [Table 2].

Table 2: Critical appraisal of the included studies

Synthesized findings

The findings, categories, and synthesized findings are shown in Figure 2.

Figure 2: Summary of findings and categories for each synthesized finding.(U, Unequivocal; E, Equivocal; Un, Unsupported)

Synthesized finding 1 was integrated from 16 findings which were merged into one category.

Category 1: Psychological distress.Infected individuals who did not have a medical or travel history relevant to an infectious disease were not able to accept their diagnosis, for example, “Surely not, how could it be such a coincidence? It may be a cold.”[1]Some felt uncertain about the treatment,for example, “It was said on the Internet that there were no specific drugs.”[1]However, others were afraid of becoming disease spreaders, and even more afraid of the disease being spread by others, for example “The greatest fear I have is harming my family.I was afraid of having transmitted the disease to my family, my parents, or my wife;”[15]“It was scary thinking I could have infected my cancer patients and coworkers and cause them to die.”[19]Many worried that they might be discriminated against by society, for example, “I have an infectious disease.The hospital isolates me for treatment… Will my teachers and classmates dare to approach me in the future?;” “I felt ashamed and did my best to avoid it.”[19]“It feels like the plague, others will definitely dislike me, so shameful.”[1]

Synthesized finding 2 was integrated from 10 findings which were merged into two categories.

Category 2: Self-coping strategies.Some infected individuals tried to divert their attention from the disease and actively sought the help of professional counselors, for example, “…I played online games, watched funny videos.to divert my attention;”[1]“I cooperated with the psychological counselor via telephone consultations and adjusted myself.”[14]When the condition became stable, patients gradually accepted the facts, for example, “After the results of the second viral nucleic acid test were over, I felt relieved.I told myself that this is a kind of disease and I’m going to accept it.”[14]

Category 3: Needs and expectations.Patients were hopeful for recovery and needed more informational support from health-care professionals about the infectious disease, for example “In fact,my condition is stable… I am looking forward to recovery… but I always expect the doctors and nurses to look at me more…give some brief information about my conditions and infection.”[1]

DISCUSSION

Meta-synthesis in this review

The data synthesis was followed by a JBI meta-aggregative approach, and a critical appraisal for the quality of methodology was conducted by two independent reviewers using JBI-QARI.The ConQual ranking system was used to establish the dependability and credibility of synthesized findings.The quality of included studies was rated as moderate to high.Two synthesized findings were formed and rated as moderate on the ConQual score.

Six phenomenological studies and one narrative inquiry were included in this review.Both phenomenology and the narratives were guided by interpretive frameworks.Narrative research focused on individual stories told by participants.It was possible to provide thick descriptions when in-depth data are gathered.[20]Phenomenology emphasizes the common experiences for a number of individuals.It provides a rich and complete description which consists of “what”they experienced and “how” they experienced it.[21]It has been suggested that multiple methods for research designs and data collection on sensitive subjects can provide more detailed information to explain complex issues.A grounded theory study can be used to generate a theory of action or an undefined theoretical explanation, and an ethnography can interpret the shared patterns of values, beliefs, and behaviors in a culture-sharing group through participant observation approach.[22,23]Case studies can provide case descriptions through in-depth data collection from observations,interviews, audiovisual material, and documents.[21]Further qualitative studies using a variety of designs need to be conducted for exploring more comprehensive and richer data about patients’ psychological experiences.The illustrations included in this review depicted subjective data for providing perspectives into the psychological experience of participants.In total, 87 participants aged 20-73 years took part in eligible studies.The differences in the experience and perspectives of people at different ages may affect the interpretations of their feelings, experience, or views on the COVID-19 pandemic.However, none of the included studies conducted in-depth explorations on psychological feelings by different age groups.In this review, the disease severity was ranged from mild to severe, but in each included study, there was no examination of patient experience based on degrees of disease severity.It means that further research is needed to deeply explore and discuss the experience and feelings of patients of different ages and the severity of disease.

Furthermore, the synthesized findings showed that patients had a range of psychological experiences at different stages of the pandemic.During the early phase of the pandemic,patients experienced psychological distress such as fear,depression, helplessness, homesickness, loneliness, guilt, and shame.It is possible that these feelings were caused by the uncertainty of the infection and treatment.[24]Patients needed more informational support from health-care professionals.[1]With the accumulation of disease knowledge and experience,the guidelines for infection prevention and disease treatment are continuously updated, the treatment effect is continuously improved, and the patient's condition has changed from severe to mild.Due to this, patients gradually developed confidence in their recovery.[1,14]The findings of this review serve as a basis for exploring the psychological experience of infected individuals and detecting their needs and expectations.The literature has suggested that sufficient medical resources, up-to-date and accurate disease information,support from health-care professionals, and the company of loved ones are needed to help patients relieve psychological distress and improve their resilience to the disease.[18]Social support becomes an important determinant of physical and psychological well-being.A Bayesian network meta-analysis showed that supportive treatment related to psychological crisis in people with COVID-19 has a better effect on the management of anxiety symptoms, while intervention is better for psychological crisis, particularly depression.[25]Studies have shown that telephone and web-based interventions are effective in alleviating symptoms of depression, anxiety, and posttraumatic stress disorder.[26,27]Health-care professionals should pay attention to the role of psychological support to help patients reduce the negative psychological impacts caused by the infection.Regional and global platforms of multidisciplinary cooperation are also needed to share information and solutions to develop protocols and adequate standards for psychological support interventions.

Limitations

The design of the studies included in this review mainly adopted a phenomenological design using semi-structured interviews;therefore, this review lacked a diversity of research designs,affecting the comprehensiveness of the synthesized findings.The quality of qualitative research and the rigor of research findings still need to be further improved.In qualitative studies, the quality of research findings may be influenced by the researcher’s preconceived ideas, assertions, and reactions to the situation.Most of the included studies did not clarify the values of the researchers and their impact on the outcome interpretations.In addition, studies that met the inclusion criteria were from five countries.Each country has its own culture, and cultural diversity exists in different countries.High-quality studies need to be conducted in a multicultural context to better understand the psychological feelings of patients.

CONCLUSION

The meta-aggregation approach was used to synthesize the findings from seven qualitative studies in five countries (United States, Iran, India, China, and Nigeria).The dependability and credibility of the synthesized findings were rated as moderate by the ConQual ranking system.The findings of this review provided in-depth interpretations of the psychological experience of the individuals infected during the pandemic.Health-care professionals should be committed to paying attention to the psychological distress of patients as well as their needs and expectations.Patients need to be encouraged to adopt effective coping strategies for promoting psychological well-being.

Acknowledgment

The authors would like to thank research funding from the Macao Polytechnic University (Code: RP/ESCSD-02/2021).

Financial support and sponsorship

The study is sponsored by research funding from the Macao Polytechnic Institute (Code: RP/ESCSD-02/2021).This review is the initial part of this project.

Conflicts of interest

There are no conflicts of interest.