Exploring the Health Literacy and Health Situation of School Principals and Vice Principals in Punjab, Pakistan: Insights from an Online-Based Survey during the COVID-19 Pandemic (preprint)

Background This study aimed to evaluate health literacy and general health status among school principals and vice principals in Pakistan, 1) to identify work-related factors associated with them, and 2) to determine their association with physical and mental health, particularly in the context of the COVID-19 pandemic.Methods An online-based cross-sectional survey was conducted among 350 school principals and vice principals in Punjab province, Pakistan. The study was conducted under the COVID Global Health Literacy Network. Data related to socio-demographic characteristics, health literacy, general health status, chronic illnesses and impairment, well-being, psychosomatic complaints, and emotional exhaustion were collected. We applied bivariate analyses as well as binary and multivariable logistic regression analyses.Results Over half of the respondents (66.6%) had sufficient levels of health literacy. A good general health status was reported by 80.3%. One of the strongest predictors of health literacy and general health status was school position (principals vs. vice principals). Additionally, those with sufficient health literacy were less likely to have frequent emotional exhaustion; while those having good general health status were less likely to report low well-being, frequent emotional exhaustion, and psychosomatic complaints. The study also found that females were less likely to have a good general health status (OR = 0.45) and were more likely to have frequent emotional exhaustion (OR = 1.75) as well as psychosomatic complaints (OR = 1.94) than males.Conclusions Limited health literacy in school leaders requires interventions for better decision-making on health matters, emphasizing the need for targeted training programs.

Social isolation emanated psychological exhaustion and disconnectedness among physicians during the COVID-19 pandemic: Results of a qualitative study in Pakistan (preprint)

Background: During the COVID-19 pandemic, many healthcare providers remained on call in COVID-19 wards, isolation centres, and emergency departments, caring for both infected and non-infected patients. Physicians have faced various challenges during the pandemic, including the stress of working with limited resources, the physical burden of long work hours and fear of public abuse in terms of stigmatization. Therefore, this study focusses on social-psychological aspects of isolation period of physicians during the COVID-19 pandemic. Methods: It is a qualitative study based on responses from 14 physicians working in two hospitals located in Islamabad, which is the capital city of Pakistan (Pakistan Institute of Medical Sciences [PIMS] and PolyclinicHospital). In-depth interviews were conducted with selected physicians by using an interview guide as a tool of data collection to explore the experiences of those physicians who suffered from COVID-19 and lived in isolation as their quarantine period. The data was analyzed by using thematic analysis technique. Results: The study explored isolation experiences of physicians during the selected period of COVID-19 and significantly found that two major themes emerged, i.e. psychological exhaustion (depression, anxiety and loneliness were subthemes) and disconnectedness (relational detachment and lack of interaction were subthemes). Conclusions: This pandemic crisis has significantly resulted in having adverse impact on the ability of physicians to approach both potential and existing patients. Particularly in times of such a crisis, adequate measures have to be taken to address mental health issues of the health workforce.

Development and validation of the Post-Pandemic Fear of Viral Disease scale and its relationship with general anxiety disorder: A cross-sectional survey from Pakistan (preprint)

Background: Given the worldwide reach of COVID-19, media coverage has amplified the psychological and social effects of this pandemic causing a widespread fear. Despite substantial research on the short-term psychological impact of COVID-19, its long-term consequences on mental health remain relatively unexplored. This research aims (i) to develop and validate a Post-Pandemic Fear of Viral Disease (PPFVD) scale and (ii) to investigate the presence of fear of viral diseases and its association with general anxiety disorder among the Pakistani population. Methods: A cross-sectional online-based survey was conducted with 457 respondents in August and September 2022. We adopted the modified fear of coronavirus scale (FCV-19S) consisting of seven items and the Generalized Anxiety Disorder (GAD) questionnaire to measure anxiety disorder. Confirmatory factor analysis was applied using the maximum likelihood estimation method. Scale dimensions and item reliability were tested for their validity and goodness of fit. SPSS and AMOS were used for data management and analyses. Results: All inter-item correlations were found to be significant and ranged between 0.30 and 0.70. The value of Cronbach’s alpha was 0.887, indicating good reliability. Corrected item-total correlations ranged between 0.632 and 0.754. Factor loadings ranged from 0.664 to 0.810, indicating a good internal consistency. Overall, these results clearly demonstrate that the one-factor solution model for PPFVD presents a good fit to the data. The composite reliability (CR=0.747) was also good. Conclusions: The COVID-19 pandemic has negatively affected the mental health of people globally. This measurement scale can be trusted and used to test the PPFVD in the post-pandemic situation. Prospective research might validate this instrument in newly emerging scenarios and test it with diverse ethnic groups.

COVID-19 Vaccination Acceptance in the Context of the Health Belief Model: Comparative Cross-Sectional Study in Punjab, Pakistan (preprint)

One of the models that could be used to understand the adoption of vaccine uptake is the Health Belief Model (HBM). The aim of this study is to assess the role of HBM constructs and perceived health status (PHS) on vaccination status of individuals and to understand the role of socio-demographic variables on HBM scoring. A comparative cross-sectional telephone survey was conducted among 1,325 vaccinated (60.0%) and non-vaccinated (40.0%) vaccinated individuals aged 40 years and above in July 2021 in Punjab province, Pakistan. A higher level of education was the strongest predictor of positive HBM. All constructs of HBM, PHS and cues-to-action were significant predictors of COVID-19 vaccination uptake with perceived benefits as the strongest predictor. In order to expand the vaccination coverage, doubled pronged interventions utilizing both ICT and human resources should be designed that address each barrier perceived by individuals and understandably communicate the benefits of COVID-19 vaccine to the broader population.

Validation of the Fear of COVID-19 Scale and its relationship with preventive behavior and anxiety disorders in Pakistan (preprint)

Background: COVID-19 has caused a huge wave of fear across many nations around the globe. From a theoretical point of view, it is argued that fear induced by an imminent threat leads people to take defensive measures and at the same time creates psychiatric disorders. We conducted this study to validate the Urdu (national language in Pakistan) version of the Fear of COVID-19 Scale in the Pakistani context. We also examined the relationship between fear and 1) preventive behavior and 2) anxiety disorders among the general population. Methods: We collected data from 2005 respondents across the country and confirmed the validity of the Urdu version of this scale. Structural analysis uncovered that fear of COVID-19 significantly predicts preventive behavior and anxiety disorder among respondents. Results: This study confirms that fear of COVID-19 has aroused mixed feelings among the population in Pakistan. Fear of contracting COVID-19 has induced the masses to take preventive measures, while at the same time, it has also produced feelings of anxiety. Conclusions: Previous research in this field also reported that fear of COVID-19 contributed significantly to mental health problems. Therefore, health authorities and governments must take measures to ensure mental health through psychosocial interventions.

Experiences Shared by the (Future) Public Health Workforce during the COVD-19 Pandemic in Germany: Results of A Survey on Workload, Work Content, and Related Challenges among Students and Young Professionals (preprint)

Although previous studies have focused on the adverse effects of the COVID-19 pandemic on various professional groups (particularly in the health and nursing care sector), this study aims to close a research gap by assessing perspectives of students and young professionals in epidemiology and public health in Germany in terms of shifts in workload, work content, and related challenges caused by the pandemic. We conducted a cross-sectional survey between mid-February and mid-March 2022. Quantitative data were analyzed via standardized mean differences. Qualitative data based on answers to open-ended questions were analyzed via a qualitative content analysis. Overall, 172 individuals participated in this survey. Results indicate that students felt burdened the most by lack of exchange with other students and lecturers. Study participants employed in public health experienced changes in their employment, because they had changes in their work content- and administration-wise, which was accompanied with a high burden due to the workload. Multiple demands that can have an impact on both acquired skills and mental health during the professional qualification phase were mentioned by the participants. Therefore, more in-depth analyses are needed for investigating the impact the pandemic will have on the (future) public health workforce in the long run.

Role of Positive Mental Health in Reducing Fears related to COVID-19 and General Anxiety Disorder in Khyber Pakhtunkhwa, Pakistan (preprint)

Background: The outbreak of the novel coronavirus disease (COVID-19) has posed multiple challenges to healthcare systems. Evidence suggests that mental well-being is badly affected due to compliance with preventative measures in containing the COVID-19 pandemic. This study aims to explore the role of positive mental health (subjective sense of wellbeing) to cope with fears related to COVID-19 and general anxiety disorder in the Pashtun community in Pakistan. Methods: A cross-sectional survey was conducted among 501 respondents from Khyber Pakhtunkhwa participating in an online-based study. We performed correlational analysis, hierarchical linear regression and structural equational modeling (SEM) to analyze the role of mental health in reducing fears and general anxiety disorder. Results: The results of the SEM show that positive mental health has direct effects in reducing the fear related to COVID-19 (β=-0.244, p<0.001) and general anxiety (β= -0.210, p<0.001). Fears of COVID-19 has a direct effect on increasing general anxiety (β=0.480). In addition, positive mental health also has an indirect effect (β=-0.117, p<0.001) on general anxiety (R2=0.32, p<0.001) through reducing fear of coronavirus. Conclusion: Based on these findings, there is a need to develop community health policies emphasizing on promotive and preventive mental health strategies for people practicing social/physical distancing. 

COVID-19 and Health Information Seeking Behavior: Digital Health Literacy Survey Amongst University Students in Pakistan (preprint)

Amid to the COVID-19 pandemic, digital health literacy (DHL) has become a significant public health concern. This research aims to assess information seeking behavior, as well as the ability to find relevant information and deal with DHL among university students in Pakistan. An online-based cross-sectional survey, using a web-based interviewing technique, was conducted to collect data on DHL. Simple bivariate and multivariate linear regression was performed to assess the association of key characteristics with DHL. The results show a high DHL related to COVID-19 in 54.3% of students. Most of the Pakistani students demonstrated ~50% DHL in all dimensions, except of reliability. Multivariate findings showed that gender, sense of coherence and importance of information were found to be significantly associated with DHL. However, a negative association was observed with students’ satisfaction with information. This led to the conclusion that critical operational and navigations skills are essential to achieve COVID-19 DHL and cope with stress, particularly to promote both personal and community health. Focused interventions and strategies should be designed to enhance DHL amongst university students to combat the pandemic.

Anxiety amongst physicians during COVID-19: Cross-sectional study in Pakistan (preprint)

Background: Ensuring safety and wellbeing of healthcare providers is crucial, particularly during times of a pandemic. In this study, we aim to identify the determinants of anxiety in physicians on duty in coronavirus wards or quarantine centers. Methods: : We conducted a cross-sectional quantitative survey with an additional qualitative item. Five constructs of workload, exhaustion, family strain, feeling of protection, and anxiety were measured using items from two validated tools. Modifications were made for regional relevance. Factor analysis was performed showing satisfactory Cronbach alpha results. Overall, 103 physicians completed the questionnaire. Results: : T-test results revealed significant associations between gender and anxiety. Structural equation modeling identified that high workload contributed to greater exhaustion (β=0.41, R 2 =0.17, p<0.001) and greater family strain (β=0.47, R 2 =0.22, p<0.001). Exhaustion (β=0.17, p<0.005), family strain (β=0.34, p<0.001), and feelings of protection (β=-0.30, p<0.001) significantly explained anxiety (R 2 =0.28). Qualitative findings further identified specific needs of physicians with regard to protective equipment, compensation, quarantine management, resource allocation, security and public support, governance improvement, and health sector development. Conclusions: : It is imperative to improve governmental and social support for physicians and other healthcare providers during the corona pandemic. Immediate attention is needed to reduce anxiety, workload, and family strain in frontline practitioners treating coronavirus patients, and to improve their (perceptions of) protection. This is a precondition for patient safety.

Challenges in providing surgical procedures during the COVID-19 pandemic: Qualitative study among Operating Department Practitioners in Pakistan (preprint)

Background Operating Department Practitioners (ODPs) are neglected human resources for health with regard to both professional development and research for patient safety. The surgical theatre is associated with the highest mortality rates and with the onslaught of the COVID-19 pandemic. ODPs are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics.Methods A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes.Results Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear.Conclusions The public health sector, in Pakistan and other developing regions, need to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwise.

Challenges in Providing Surgical Procedures During the COVID-19 Pandemic: Qualitative Study Among Operating Department Practitioners in Pakistan (preprint)

Background: Operating Department Practitioners (ODPs) are neglected human resources for health with regard to both professional development and research for patient safety. The surgical theatre is associated with the highest mortality rates and with the onslaught of the COVID-19 pandemic. ODPs are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics.Methods: A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes.Results: Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear. Conclusions: The public health sector, in Pakistan and other developing regions, need to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwise.

Socio-cultural challenges in the implementation of COVID-19 public health measures: Results from a qualitative study in Punjab, Pakistan (preprint)

Background: Informed public health measures are crucial to curb the COVID-19 pandemic. The socio-cultural context is important to understand the success or failure of implementing public health measures. This study explores the social and behavioral response to COVID-19 and unveils challenges in the implementation of related public health measures in Pakistan. Methods: Within this qualitative study, we conducted 34 telephonic/online in-depth interviews with youths, adults, old-age people, and healthcare professionals in the Punjab province of Pakistan. Framework analysis was used for data analysis. Results: People’s poor understanding about COVID-19 and the need for preventive measures were the major challenge in implementation of public health preventive strategies. Study participants reported that the lockdown strategy increased poverty and unemployment. People’s poor living conditions and living environment compelled them to not follow social distancing and restricting themselves to homes. Additionally, an underdeveloped healthcare system was one of the major challenges for Pakistan. False and misleading information about the disease had significant consequences for the COVID control program. In Pakistan, the culture of denial related to the epidemiology of COVID-19 were important challenges within the implementation of public health preventive measures. Conclusions: It is extremely important that public health experts and social scientists work together to understand the contextual socio-cultural factors which shape behaviors associated with the spread of a pandemic. This knowledge is needed in order to design and implement preventive strategies that could effectively work in the local context.

Psychosocial Challenges Faced by Female Health Care Professionals During the COVID-19 Outbreak in Lahore, Pakistan: A Qualitative Study (preprint)

Background: The novel coronavirus disease (COVID-19) is disseminating rapidly, increasing stress and challenges for health care professionals around the world. This study aims to discover the psychosocial challenges faced by female health care professionals (HCPs) treating COVID-19 patients in Pakistan.Methods: Using an empirical phenomenological methodology, semi-structured telephone-based qualitative interviews were taken from 22 female HCPs who were providing their expertise for COVID-19 patients in tertiary level hospitals of Lahore, Pakistan. Purposive sampling has been used for recruitment. The interviews were taken from July 20 to August 20, 2020. The interviews were analysed using thematic analysis.Results: This study discovered the psychosocial challenges faced by female HCPs serving COVID-19 patients. Five themes have been observed in the interviews: psychological concerns of HCPs while treating COVID-19 patients; feelings towards COVID-19 patients; confidence in government, administration and self-reflection; challenges as female HCPs and coping strategies; and finally, future concerns and recommendations. Many of these themes have also been linked with cultural issues, making the results specific for Pakistan.Conclusions: During the COVID-19 pandemic, female front-line HCPs have faced immense psychosocial pressure, starting from unsupportive family norms to unwelcoming working environment and insensitive hospital administration. Moreover, rumours among general public, lack of proper training, missing incentives and improper system surveillance had increased the anxiety and stress among HCPs. Hence, legislators are advised to take appropriate actions countrywide in order to improve the still on-going challenges and to support female HCPs in their working environment.

Role of the Media in Health-Related Awareness Campaigns on Perceptions of COVID-19: A Pre-Post Study in the General Population of Pakistan (preprint)

Background: In January 2020, the World Health Organization declared the COVID-19 outbreak a global public health emergency. Medical preparedness and community education are the most valuable preventive tools for combatting this pandemic. The objective of this study was to assess the role of media public health awareness campaigns on the knowledge of the general population about COVID-19 in Rawalpindi, Pakistan.Methods: A quantitative study using a pre-post design among 384 respondents was conducted. To recruit study participants, a systematic random sampling technique was used. A structured questionnaire was administered to the participants twice: The first response (t1) from participants was filled in during the first week in February 2020 before any confirmed cases were reported in the country, and the second response (t2) was completed one month after the first case detection in Pakistan (March 2020). Media health awareness campaigns were launched just after the detection of the first case in Pakistan. Data was analysed by computing descriptive statistics and paired t-tests to measure the level of association between variables.Results: Exposure to the media and knowledge relating to COVID-19, particularly its symptoms and frequent handwashing as a preventive measure, increased over time. Whereas only a quarter of respondents judged the isolation of suspected cases in quarantine to be important to prevent the spread of infection in society at t1, more than half did so at t2. The same increase was visible in relation to the statement that a lockdown helps to follow social distancing. Socio-demographic characteristics were not significantly associated with knowledge (gains). However, more frequent use of electronic media is associated with greater knowledge gains from t1 to t2.Conclusions: The findings of this study provide evidence that awareness and knowledge related to COVID-19 symptoms and preventive measures increased significantly over time. The increased frequency of following the media indicates that health awareness campaigns are important for enhancing the knowledge of the general public regarding COVID-19.

Experiences of Frontline Pakistani Emigrant Physicians Combating COVID-19 in the United Kingdom: A Qualitative Phenomenological Analysis (preprint)

Background: This study aims to explore the experiences, beliefs, feelings and challenges faced by Pakistani migrant doctors working in the United Kingdom in times of the COVID-19 pandemic. This qualitative approach was chosen to document their lived experiences and to develop a post-COVID-19 response to help them recover from their shared and individual traumas.Methods: An empirical phenomenological approach was used to collate data on experiences made during the COVID-19 pandemic. Purposive and snowball sampling was used to target participants, which were doctors of Pakistani origin involved in the direct care and management of COVID-19 patients in different NHS hospitals of the United Kingdom. Semi-structured, in-depth telephonic interviews were conducted with study participants in May 2020. Data collection was done parallel with data analysis by using standard qualitative methods.Results: We recruited ten frontline physicians. Four theme categories emerged from the data analysis: 1) Working across borders and cultures, 2) Role of beliefs for coping stress and fear, 3) Passion and profession, and 4) Scaffolding the Pakistani health system. Overall, the results show that the participants received no professional support, in terms of counselling and psychological rehabilitation. Instead, they had to use self-management strategies to cope with the situation. Conclusion: The intensive work exhausted participants physically and emotionally. They were holding a lot of grief and hurt inside; but still healthcare professionals showed the spirit of professional dedication to overcome difficulties. Although currently coping with their emotional problems, comprehensive professional support should be made available to them in order to cater for the wellbeing of frontline physicians.