The present study found that people’s poor understanding of COVID-19 and need for preventive measures, such as physical distancing, were the major challenges in implementing public health preventive strategies during the COVID-19 pandemic. Global experiences and growth patterns of the pandemic clearly indicate that COVID-19 is directly linked to social behaviors. Social construction of health and illness in any society plays a significant role in the health seeking behavior. Knowledge or awareness about the risks associated with any disease significantly influence what preventive measures people adopt or refuse to adopt. Graham’s paradigm of disease development emphasizes to contextualize an epidemic within the social situations in which it occurs . It highlights that timely understanding of social behaviors associated with the spread of an epidemic can help to frame an effective public health strategy.
Due to diverse local cultural beliefs and sources of knowledge, population sub-groups vary in health risk perceptions. Owing to illiteracy, a traditional belief system, and economic compulsions many people even do not consider COVID-19 as a serious public health risk [7, 12, 16]. A survey conducted in Pakistan assessed the knowledge and practices of people about COVID-19. It shows that people have a limited understanding of COVID-19, especially related to symptoms associated with the disease. Furthermore, gender was slightly associated with the knowledge about the disease . Another study showed significant differences in knowledge and practice of coronavirus preventive measures. However, despite having knowledge about the disease people did not practice preventive measures . Moreover, a majority of the surveyed people were of the view that government and opposition were not on the same page in the fight against the coronavirus. More than a half of the study population had misconceptions about COVID-19 . Therefore, it becomes imperative that public health awareness strategies should counter the myths and misperceptions associated with the pandemic and provide appropriate knowledge.
One of the most effective public health measures to counter the rapid growth of COVID-19 is social distancing. Several studies and epidemiological modeling have shown that the patterns of social networks or social contacts strongly influence the spread of disease in a population [19, 20, 21]. The behavior of people greatly influences the consequences of any public health intervention. Link names this “social shaping of population health” . However, many of our study participants were not agreed with the concept of social distancing. As social distancing was extremely difficult to practice in densely populated countries like Pakistan, where a significant number of people live under one roof along with extended families. Furthermore, they tend to believe that going to public places does not expose them to higher risks than confining themselves in homes, where already a large number of people is living together . In such cases, even when someone is not feeling well, other family members share the same room because they do not have any other option . Large gatherings at times of happiness and sorrow, handshaking and embracing are part of everyday lives of people in Pakistan. Amid the outbreak of COVID-19, public health measures require people to change their routine behaviors to prevent the rapid spread of the coronavirus. Such a sudden change in everyday life is still a cultural shock for many people and they consider it as a threat to their culture. Despite the lockdown and restrictions on gatherings and going to public places, people are not taking the pandemic seriously and are still arranging gatherings for marriage, funeral, parties or other purposes .
Financial and skilled human resources are very important to combat any health emergency. A developing country like Pakistan, with strained political and economic structures, is already struggling to tackle poverty, extremism, and other human insecurities. Therefore, a global pandemic such as COVID-19, could be much more devastating in developing countries than in developed ones [7, 24, 25]. In Pakistan, the health sector has not been a priority of the successive governments. Only about 2% of its gross domestic product are spend on healthcare – compared to a global average of 10% . Until now, the country has not been able to control diseases that have been eliminated elsewhere in the world, e.g. polio . The ministry of health has already issued warnings to be mindful of the pandemic as the resource-limited country is not well-prepared to control any drastic situation caused by the pandemic. If coronavirus cases are not controlled, diagnosed and timely treated, the situation may lead to a more devastating crisis . At the time when corona hit the country, there were 2,200 ventilators available in hospitals, out of which only about half were functional . The fragile public health infrastructure does not have the capacity to provide treatment to tens of thousands of patients of COVID-19, and the major threat for Pakistan is high fatalities due to lack of healthcare services [11, 13].
As the backbone of health infrastructure, physicians, paramedics and nurses are considered frontline fighters against COVID-19. However, they are also extremely vulnerable to get infected in the absence of personal safety measures . Frequently cases are reported in different parts of the country where doctors and paramedics have refused to perform their duties and are protesting due to the lack of availability of personal protective equipment [11, 26, 27]. With already limited healthcare services available in the country, the strike of healthcare personnel and their vulnerability to fall victim of the disease might lead to serious consequences in combatting the pandemic.
In a situation of global health emergency, governments need to take quick proactive public health measures to avoid spreading the pandemic. In Pakistan, many people believe that the government could not assess the severity of the issue and delayed framing its response strategy mainly due to the lack of political consensus [5–8, 28]. Initially, coronavirus-positive cases were detected in Pakistan among those persons who had recently visited the neighboring country Iran, where COVID-19 had already spread [29, 30]. However, at an early stage of the epidemic spread, due to a lack of proper coronavirus testing services and quarantine facilities in the remote town Taftan in Baluchistan province, bordering Iran, there was not proper screening of the visitors coming back to the country. Therefore, it became a source of spreading the virus .
In addition to the lack of healthcare services and knowledge about COVID-19, fear and stigmatization associated with the disease also restrict people to seek early medical advice . The study participants in our study perceived that – like other infectious diseases – coronavirus-positive cases are being stigmatized, because they might be responsible to transmit the virus to other people. Moreover, some television channels breached the individual privacy by revealing the personal identities of those people who tested positive and showed clips of ambulances and police vans going to their homes as they were being “arrested”. One study also indicated that a majority believed that coronavirus-related news on media were exaggerated in Pakistan . Further, many people had developed fears of getting exposed to the virus or testing positive, and, therefore, stayed away from hospitals – even when they were not feeling well. Several alarming cases in different parts of the country have been reported in which confirmed and suspected patients of COVID-19 fled from the quarantine/isolation centers . Such irrational behavior was not only life threatening for patients but also exposed others to the virus.
Another significant challenge within Pakistan was to regulate religious gatherings and ritual practices to prevent the transmission of COVID-19. Due to diverse opinions among religious leaders, it has been a daunting task for the government to develop a consensus on the sensitive issue of religious gatherings . Many people in Pakistan believe that the coronavirus is a punishment of sins from God. Hence, instead of sitting at home, people should gather in mosques and collectively pray to protect them from the epidemic [7, 16, 35]. Even some people are not following the basic preventive measures, wearing masks and maintaining social distance, considering that nothing can happen to them except what already is their fate . Many refused although authorities held several meetings with the clerics to convince them to cooperate with the government in the implementation of the public health measures and restrict congregational prayers and rituals . Therefore, public health experts were of the view that congregational prayers could potentially result in the “explosion” of coronavirus cases in the country .
Moreover, developing countries like Pakistan are less likely to enforce appropriate preventive measures and become more susceptible to high penetration of any epidemic due to grave socioeconomic disparities and lack of access to basic services, e.g. water, sanitation, food, and shelter [5, 37, 38]. Health risks are strongly associated with lifestyles shaped by socio-economic structures, as those segments of the population that are already marginalized tend to be more vulnerable to be infected . In Pakistan, the majority of the population does not have access to clean water even for drinking. Washing hands regularly as a preventive measure against COVID-19 is therefore seen as “an unimagined luxury” . Moreover, millions of slum dwellers in the country are among the most vulnerable groups to get infected as maintaining personal hygiene and social distancing could not be practically possible for them [5, 7, 23]. In a lockdown situation, there is no option to work from home or stay at home for poor and daily wagers. Further, the country is amongst the top malnourished countries in the world as a significant proportion of the population does not have access to basic healthy food which makes them susceptible to acquiring the disease .
While many countries have ordered the lockdown to prevent the spread of COVID-19, reality is much different in countries like Pakistan, because the lockdown could result in more severe fatal consequences than the pandemic itself. Almost one-fourth of the total population of the country lives under conditions of poverty and earns less than $2 a day [12, 29, 30, 39]. For such underprivileged groups, the coronavirus is not only a health problem but an economic challenge . After the outbreak of COVID-19 in Pakistan, the government announced a partial lockdown, which still continues with gradual relaxation as millions of people are daily wagers who cannot survive without work for a longer period. Despite limited economic resources, the government announced a support package which was directly distributed among 12 million low-income families . However, the gatherings of a large number of people to receive the financial assistance at designated places could be a public health risk breaching social distancing measures . Moreover, keeping in view the large size of the population and density of poverty within Pakistan, it would not be possible for the government to support every needy family and confine them to home for a longer period.
The study findings may not be representative for Pakistan, because the study was conducted in only one province. However, we recruited a large sample size for a qualitative study. The heterogeneous sample allows for including various perspectives in the analysis.
The interview guide was developed based on concepts that emerged from the literature review and expert opinions. This allows for including relevant aspects, although one needs to keep in mind that the COVID-19 pandemic is also characterized by uncertainty and rapidly changing situations. Further studies are needed which focus on culturally and regional specific aspects promoting or hindering the implementation of public health measures in times of a pandemic.