The Mental Health Crises of the Families of COVID-19 Victims: A Qualitative Study

doi:10.21203/rs.3.rs-35698/v1

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The Mental Health Crises of the Families of COVID-19 Victims: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-35698/v1

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published 15 May, 2021

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Background: The bereaved families of COVID-19 victims are among the most vulnerable social groups in the COVID-19 pandemic. This highly infectious and contagious disease has afflicted these families with numerous psychological crises which have not been studied much yet. The present study is an attempt at investigating the psychological challenges and issues which the families of COVID-19 victims are faced with. The present study aims to identify the Mental Health crises which the families of COVID-19 deceased victims are going through.

Methods: A qualitative research, the present study uses a conventional content analysis design. The participants were 16 members of the families of COVID-19 victims selected from medical centers in Iran from February to May 2020 via purposeful sampling. Sampling continued to the point of data saturation Data were collected via semi-structured individual interviews conducted online. The collected data were analyzed according to the conventional qualitative content analysis approach.

Results: Analyses of the data yielded two main themes—emotional shock and fear of the future—with nine categories.

Conclusion: The families of COVID-19 deceased victims are affected by various psychological crises which have exposed them to a deep sense of loss and emotional shock. In addition, the instability in the family following the loss of a family member and job insecurity due to the COVID crisis have caused them to be very worried about the future. Therefore, there is an urgent need for a cultural context which recognizes and supports all the various aspects of the mental health of these families.

General Practice

Mental health crisis

victims

family

COVID-19

qualitative research

COVID-19 has been the most horrifying emerging disease in recent decades (1, 2), spreading extreme fear across the whole world (3). Emerging diseases are diseases which appear for the first time in a certain area or the world, have high severity, and quickly infect a large population (4, 5). According to World Health Organization in recent years, more than 30 emerging infectious diseases have appeared in different parts of the world and each of them has been of significance based on its type, spread, and seriousness (3, 6). Since there is not a specific treatment for most emerging diseases, they take on epidemic proportions and spread across wide geographic areas, increasing the number of infections and deaths and, consequently, imposing considerable expenses on healthcare systems (7). A case in point is COVID-19 which started from China in 2019 and continued to spread widely in over 200 countries, including Iran (8).

The initial symptoms of COVID-19 are similar to those of the flu, but the infection gradually spreads and affects the cardiopulmonary and renal systems. The infected often have signs of dyspnea, tachypnea, and respiratory failure, but, so far, no treatments or vaccines have been developed for COVID-19 and the patients can only be given supportive care (9, 10). The little-known nature of COVID-19, constant changes in the genetic structure of the virus, occurrence of new symptoms in the infected, and, most importantly, lack of a definite treatment or specific vaccine for the disease have led to the infection of more than 1 million people worldwide in the past three months, 200,000 of whom in the world and 7,000 in Iran have lost their lives to this emerging disease (3, 10).

The high rate of infection and fatality of COVID-19 in the world has exposed humans to various psychological crises with very adverse effects on their lives, social activities, and, consequently psychological security (2, 11-14). The families of the victims, living or dead are among the social groups especially affected by psychological stress and tension (12, 13, 15). The death of a family member usually causes emotional shock and trauma to the other members of the family who need to receive wide emotional support from relatives and even the society to adapt to their sense of loss (16, 17). However, the sudden death of a family member to COVID-19, especially when the victim is young and does not have any underlying medical conditions, can subject families to extra shock and distress (2, 11-13). Furthermore, the majority (about 60%) of the deceased in Iran has been male and head of the family, responsible for the financial support of their families, decision making, and planning the future of their children (12, 13, 18, 19).

Obviously, the sudden loss of the head of one's family to COVID-19 exposes all the members of the family to psychological crises which adversely affect their adaptation, personal lives, and future. Identification of these crises and challenges can help relatives and caregivers take effective measures toward providing the families of the victims with better care and support. Accordingly, the present study aims to identify the psychological crises which the families of COVID-19 victims are faced with. Hopefully, the findings of the study can help healthcare mangers and caregivers facilitate the adaptation of the families of the deceased victims by providing them with proper mental health care. Therefore, the present study aims to identify the mental health crises of the families of COVID-19 deceased victims.

The present study uses a qualitative approach and relies on conventional content analysis which is used when little is known about the concept under study (20, 21). As the mental health crises of the families of COVID-19 victims have never been studied before, the researchers applied conventional content analysis. The study subjects were 16 members of families which had lost a member to COVID-19. Selected via purposeful sampling, the subjects consisted of 6 wives, 3 husbands, 5 children, and 2 mothers who represented a wide range in terms of relationship, gender, financial status, education, etc. Sampling lasted from February to May 2020 until rich data were collected. The inclusion criteria were: being Iranian, speaking Farsi, being able to provide adequate rich information, and having had their deceased family member hospitalized in a medical center designated for COVID-19 patients from the time of their diagnosis until death.

Data were collected from 16 semi-structured individual interviews which were conducted via video call in what’s App at times which suited the participants. Each interview started with a few general questions, including: "How did the infection of your deceased family member progress?", "What were your feelings from the diagnosis to the death of your family member?", and "How has this incident (loss) affected your life?", Next, based on the participants' answers, follow-up questions were asked to add to the clarity of the information: "Will you explain further?", "What do you mean by that?", and "Will you give an example?", The interviews were managed so as to gather information related to the main objective of the study.

Each interview lasted from approximately 38 to 52 minutes. Immediately after each interview, one of the researchers listened to it several times and then transcribed it. Thus, data were analyzed as soon as they were collected and the next interview was planned based on the results of its predecessors. The collected data were analyzed according to the qualitative content analysis approach: considering the explicit and implicit content of the units of meaning, key points in the manuscripts were extracted as open codes. Then, based on their similarities and differences, the codes were categorized and the process of abstraction was kept up until a theme was extracted (22). The interviews continued until data saturation was reached and no new categories emerged. To improve the trustworthiness of the results, the researchers applied Lincoln and Guba's criteria (23). Thus, the dependability and credibility of the results were increased by immersion and prolonged engagement, member check, ad peer check.

Ethical Considerations

The institutional review board of the medical universities located in the west of Iran has approved the design of the present study (approval number: 1399.256). At the beginning of each interview, the researcher introduced herself, described the goals of the study, and assured the subjects that all information would remain confidential. The researchers also assured the subjects that they were free to withdraw from the study at any stage of the research process and that their refusal to participate or withdrawal would not have any consequence for them. Then, the participants' written informed consent was obtained.

In the present study, 16 members of the families of COVID-19 deceased victims were interviewed. The participants consisted of 9 females and 7 males (6 wives, 3 husbands, 4 sons, 1 daughter and 2 mothers). The average age of the participants was 38 years. Also, the majority of them had a diploma, and they had a moderate economic level. Two main themes—emotional shock and fear of the future—with 9 categories were extracted from the data. Table 1 shows the themes and categories.

A. Emotional shock

The participants mentioned that the emotional shock caused by the loss of their family members to COVID-19 was very intense and the worst psychological crisis which they had ever had to deal with. To adapt to their current situation and overcome the pain, they needed systematic psychological support from healthcare teams. The theme of emotional shock consists of 5 categories: catastrophizing and rumination, bitter farewell, parting in desolation, concern about unreligious burial, and stigmatization.

Catastrophizing and rumination

The bereaved families in the present study stated that the sudden death of their family members had been a catastrophe and that they were constantly engaged in ruminating on it. They continuously reflect on the manner of infection of their deceased and keep thinking that they may have transferred the coronavirus to their families and caused the death of their loved ones.

"My dad just died in two days without showing any symptoms of the disease though he followed all the recommended rules of hygiene outside home and at work. But I spent a lot of time with my friends and did not follow those rules. I keep thinking, reviewing events, ruminating about it, telling myself that I could have given the infection to him. He was middle-aged and had a weaker immunity system; he got it from me and passed away. This rumination is agonizing" (Participant 2).

Bitter farewell

The participants mentioned that parting from their deceased family members had been the bitterest and saddest moment in their lives. Their deaths had been so sudden that they did not have the chance to talk to their loved ones and express their love to them for the last time. They only experienced a bitter farewell.

"My wife was a young, patient, and caring woman. I always thought I still had a lot of time to tell her how I felt about her, how much I loved her, and show my love to her. But she suddenly got sick and died. It was unbelievable. The only thing that I could tell her was a bitter good-bye" (Participant 8).

Parting in desolation

One of the most important categories under the theme of emotional shock is mournful separation. The participants stated that they never expected to have to have their loved ones buried by sanitation workers in the absence of their relatives and friends and not even have the chance to embrace them for the last time.

"My mom could barely draw in her last breaths and I was all in tears but I couldn't even hug her for the last time. And when she passed away, we couldn’t have her body. They only told us at what time and place she would be buried. At her funeral, we had to stand at a distance from her grave because of the safety regulations and none of our relatives and friends could be there. My mom was buried by sanitary workers. That agonizing separation will stay in my mind forever" (Participant 8).

Concern about unreligious burial

The participants pointed out that one of the worst psychological crises which they had experienced after the death of their loved ones was their concern that they would be buried in an unorthodox and unreligious manner. They stated that the only thing that could console them a little in that situation was to know that, even if they could not bury their loved ones in the company of their relatives and friends, they would be buried in a proper religious manner.

"We all have our own beliefs. My father was a very religious man. When he was sick, he was worried that he would be buried without getting a full ablution and a shroud (Islamic burial rites). When he passed away, my only wish was to bury him according to Islamic principles. That was a big concern to me—it was the least I could do for my father. When he was buried based on our religious rites, I was fairly relieved" (Participant 14).

Stigmatization

The participants of the present study also mentioned that being stigmatized and labeled by people after the death of their loved ones was one of the most painful psychological crises that they had experienced.

"People are terrified of this disease and try to keep away from us. It's been two months since my husband's death, but every time I'm walking down the alley and want to enter my apartment, I feel and hear people talking behind my back, calling me "virus spreader," "miserable woman," "poor thing" and so on. These names disturb me so much" (Participant 9).

B. Fear of the future

The other theme extracted from the data is fear of the future. The bereaved families of COVID-19 victims state that fear and uncertainty about the future continuously haunts them. Their main concerns were about the stability of their families, job security, their interactions, and the financial status of their families. This theme consists of four categories: instability in the family, lack of job security, complications in social interactions, and difficult financial conditions.

Instability in the family

According to the participants, death of a family member, especially the father, has a very adverse effect on the stability of the family. Many mothers cannot or are not allowed to stay with their children, which inflicts significant psychological tension on them.

"I'm 26 years old and I've lost my husband to the coronavirus. The pain is indescribable. But what is worse is that I have a 6-year-old son and my father-in-law has his custody now and he won't let me take him to live with me. I don't know what to do—I've lost my husband and if I want to move in with my parents or start a new life, he's going to take my child away from me. Can life get any more miserable? … I lost everything overnight, my family is ruined" (Participant 4).

Lack of job security

The participants also stated that fear of losing their jobs and uncertainty about employment were issues which preoccupied them and caused them considerable stress.

"I lost my mom to coronavirus. Everyone at work knows about this. Ever since my mom's death, my boss has told me not to go to work. I'm telecommuting now. But the private company I work for is reducing its workforce, and as things stand right now, I'm constantly anxious and thinking that I'm one of the first people they will fire. I'm worried this disease will ruin my job prospects and I'm afraid to lose my job" (Participant 11).

Complications in social interactions

Another important extracted category is complications in social interactions. The families of the deceased stated that COVID-19 has caused so much terror in societies and affected the interactions of the uninfected, too. In the current situation, people are terrified of interacting with the families of COVID-19 victims and would rather stay away from them. Persistence of this behavior will subject the bereaved families to serious psychological crises.

"My mother died because she had the coronavirus. Even though we were quarantined and it was determined that we weren't infected, people still keep away from us. They wouldn't walk within 10 feet of us; they don't even talk to us. My little brother was in the yard yesterday watching the other kids in our building from afar. Those kids wouldn't even talk to him. If this kind of behavior continues for a long time, my brother is going to get depressed and may suffer different psychological disorders" (Participant 16).

Difficult financial conditions

The participants pointed out that the death of their loved ones, especially fathers, as a result of COVID-19 has threatened the financial status of their families and that they were expecting financial difficulty in earning a livelihood and continuing their education.

"Our financial situation is not good. We're from the low social class. After my husband's death,our financial situation got even worse. In the past four months, we've been living on the savings we'd set aside for our daughter's college education. I don't know what we should do now. It's not easy at all to find a job either. Stores and factories don't hire new workers. I really don't know what to do, how to make a living, or how to get the money to send my daughter to college. All this financial pressure is distressing to me" (Participant 10).

Identification of the psychological crises which the bereaved families of COVID-19 victims are exposed to can guide healthcare providers in facilitating the families' adaptation and helping them recover their emotional well-being(2, 11, 12, 14). Thus, there is need for in-depth systematic research into the psychological issues and challenges of these families. In the present study, which is the first work of qualitative research in this field, the psychological crises of the families of COVID-19 deceased victims are classified into two themes: emotional shock and fear of the future.

Emotional shock is one of the major psychological crises which were extracted from the data. The families of COVID-19 victims were deprived of the company of relatives and friends at the funeral of their loved ones, could not hold a proper funeral for their deceased, and had to watch them buried in a desolate atmosphere, all of which facts subjected them to a major emotional shock. In the present study, this theme was found to consist of the following categories: catastrophizing and rumination, bitter farewell, parting in desolation, concern about unreligious burial, and stigmatization.

The characteristics of the coronavirus, including its high contagiousness (8), had caused some of the participants to engage in rumination: they thought that they may have transferred the infection to their family members, some of whom were older than them, and caused their death. This mental catastrophization led to rumination in the families of the deceased. Rumination is associated with anxiety, distress, and other unhealthy emotional conditions which indicate the presence of negative thoughts and feelings and can result in serious psychological harms (13, 24). Similarly, several other studies report that the death of a family member inflicts significant psychological tension on the other members of the family and relatives(13, 24, 25). Thus, it is necessary that healthcare providers, especially psychologists and psychiatric nurses, identify the negative thoughts of the families of the victims and take steps to protect them from rumination, catastrophizing, and emotional shock toward improving the psychological health of the society (13, 25, 26).

Although loss of a family member is a painful experience, holding a funeral in the company of relatives and friends is some consolation to the bereaved and facilitates their adaptation (27, 28). However, the last farewell of the interviewed families of COVID-19 victims to their loved ones had been very bitter: they could not be by the side of their loved ones when they were on their deathbed, could only watch from a distance when they were being buried, and could not have the company of their friends and relatives in a proper funeral. There are many other studies which report similar results: the families of the terminally ill have to part from their loved ones in a mournful manner; however, none of those studies mentions desolation in the experiences of the bereaved(28–30). Parting in desolation could have occurred during other epidemics and pandemics in the past, e.g. the Plague, cholera, etc.

The participants were also concerned that their deceased would be buried in an unethical and unreligious manner. The bereaved families expected their loved ones to be buried according to Islamic rites and believed that that was the least they could do for them in those critical times. In addition, a religious burial could bring some consolation to the bereaved and help them cope with their emotional shock and distress. The participants' insistence on a proper religious burial was probably rooted in the prevalent Islamic culture of Iran: Islam dictates that the dead should be given a full-body ablution and wrapped in a shroud before they are buried with respect. In recent years, many other studies have stressed that, toward providing ethical care, caregivers should respect the preferences and religious identity of patients and their families without judging them (21, 28).

Another serious psychological crisis which the families of the victims were going through was stigmatization. The sudden emergence of COVID-19 in Iran and in the world, shortage of personal protection equipment, lack of a definite treatment for the disease and its high fatality rate have caused people to be terrified of COVID-19 and keep the infected and their families at bay and, occasionally, call them names, including "COVID-stricken," "miserable creatures," and "poor things." Being called names aggravates the psychological tension of the families of COVID-19 deceased victims. On the same line, studies on patients with incurable diseases or psychological and behavioral disorders stress that caregivers and the whole society should treat these groups humanely and ethically and avoid all forms of stigmatization and pitying behaviors (13, 28).

The other theme extracted from the data in the present study is fear of the future. The coronavirus knows no geographic boundaries and has afflicted the people of almost every country in the world with family, economic, and social crises; however, due to the heavy sanctions which are being imposed on Iran, Iranians are under extra pressure from these crises. The families of the infected are especially affected by this pressure (12, 19). The participants of the present study stated that thinking about the future fills them with terror. They were worried about their family stability, job security, financial status, and social interactions with others.

Instability in the family is one of the main categories under this theme. Studies conducted in other cultures show that the death of a family member, especially the father or mother, threatens stability of the family due to various reasons, including financial issues and remarriage of a parent (31, 32). However, certain peculiarities in the culture and law of Iran make the bereaved families of COVID-19 victims, the wives in particular, especially worried about the stability of their families. The majority of the infected and the deceased in Iran are male and men are considered the lawful guardians of their children in the Iranian culture. In case of death of a child's father, his/her paternal grandfather or uncle becomes the lawful guardian and this fact puts the wives of COVID-19 victims with children in a crisis. Most of the times, if the mother decides to remarry these lawful guardians do not let the mother keep her child, which is a threat to the stability of the family (6, 33, 34).

On the other hand, though many people have faced financial problems in this crisis(19) the medical costs which were imposed on the families of COVID-19 victims and, if the victim was the head of the family, the loss of their source of income have put them under additional pressure financially. Earning a livelihood and paying for their children's education have become their biggest bugbear. Similarly, other studies report that the illness and hospitalization of one their members can strain the finances of many families, thus the need for the government or charity organizations to provide them with financial support.

The global crisis caused by the coronavirus has inflicted serious economic problems on many countries, Iran included: the shutdown of many factories, companies, and other businesses is threatening the job security of many people. The families of COVID-19 victims believe that they at greater risk because, though many of them are teleworking now, they are afraid that their employers may dismiss them due to the infection and death of their family members.

The fact that COVID-19 is as yet incurable and there is not a vaccine for it and the possibility that a vaccine will not be discovered for it in the near future have caused people to avoid the infected and their families and not want to have any interactions with them. Continuing social exclusion of this group will expose the families of deceased COVID-19 victims to serious psychological challenges in their social and work interactions. Thus, it is necessary that public awareness about the modes of transmission of the virus and personal protection be raised effectively so that the psychological well-being of the infected and their families will not suffer.

In conclusion, the bereaved families of COVID-19 victims are going through serious psychological crises as a result of the sudden loss of their loved ones, parting from them in desolation, social exclusion, and concerns over their family stability and job security. Accordingly, it is urgent that the healthcare system develop programs and protocols to protect the psychological and emotional well-being of this group.

One of the limitations of the present study is that, due to the high contagiousness of COVID-19 and the need for work in virtual environments at the time the study was being carried out, data were collected through personal interviews conducted via video call. Employment of other methods of data collection could have enriched the results of this work of qualitative research. It is suggested that future studies use, in addition to personal interviews, other methods of collecting qualitative data, including field notes, observation, and focus group interviews.

The spread of the coronavirus across all the provinces of Iran and the increasing number of the infected and deaths have presented the healthcare system of Iran with the biggest clinical challenge in the past decade. In this crisis, one of the important tasks of the healthcare system is to maintain the psychological health of the families of COVID-19 deceased victims. Thus, identification of the factors which threaten the psychological well-being of this group is essential. The results of the present study show that the bereaved families of COVID-19 victims experience a much deeper sense of loss and emotional shock than others. Moreover, the impact of COVID-19 on the current situation in the society has filled these families with fear of the future, with adverse effects on their psychological well-being. It appears that there is need for cultural and organizational efforts toward raising the public's awareness and creating systematic health protocols to protect the psychological health of the families of COVID-19 victims. Healthcare officials and policy-makers can use the findings of the present study to create a supportive environment free of psychological distress to maintain the mental health of these families.

Ethics approval and consent to participate

The institutional review board of the Hamadan university medical science, the Chronic Diseases (Home Care) Research Center provided ethics approval (approval number: IR.UMSHA.REC.1399.254). Also at the beginning of each interview, the researcher introduced herself and explained the goals of the study and provided assurance that all information would remain confidential and that they could withdraw from the study at any time. The researchers provided the opportunity for participants to inform the researcher about their withdrawal from the study at any stage and assured them that their lack of participation or withdrawal would not have any consequence for them. Finally, the written consent was obtained from study participants. Therefore, before the start of each interview, a written consent form was sent to them via Whats App. After completing the consent form, the interviews were planned and implemented.

Consent for Publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request

Competing interests

The authors declare that they have no competing interests.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

Acknowledgment

The present article is the outcome of a research project registered at Hamadan University of Medical Sciences. The researchers are grateful to the authorities at the school of nursing and midwifery of the Hamadan University, the Chronic Diseases (Home Care) Research Center, the participants, and other individuals who helped them for their cooperation. Authors’ contributions

FM, MB, KhO, FSh and FCh were involved in the conception of the study, and designed the study. They are responsible for data collection, data analysis and interpretation. FM, MB and KhO drafted the primary manuscript, revised and approved the final manuscript.

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Table 1. Themes and subcategories extracted from content analysis
Theme	subcategories
*Emotional shock*	*Catastrophizing and rumination* *Bitter farewell* *Parting in desolation* *Concern about unreligious burial* stigmatization
*Fear of the future*	*Instability in the family* *Lack of job security* *Complications in social interactions* *Difficult financial conditions*

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Journal Publication

published 15 May, 2021

Read the published version in BMC Primary Care →

Editorial decision: Major revision
01 Feb, 2021
Review #2 received at journal
24 Jan, 2021
Reviewer #2 agreed at journal
01 Oct, 2020
Review #1 received at journal
10 Sep, 2020
Reviewer #1 agreed at journal
20 Aug, 2020
Reviewers invited by journal
31 Jul, 2020
First submitted to journal
16 Jun, 2020
Editor assigned by journal
16 Jun, 2020
Submission checks completed at journal
15 Jun, 2020
Editor invited by journal
15 Jun, 2020

You are reading this latest preprint version

The Mental Health Crises of the Families of COVID-19 Victims: A Qualitative Study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Discussion

Limitations

Conclusion

Declarations

References

Tables

Status:

Journal Publication

Version 1