Perceptions and Experiences of COVID Recovered Individuals Regarding Psychological Distress in Sialkot

This study explores the perceptions and experiences of COVID recovered individuals regarding psychological distress, and the effects of COVID-19 on their mental health, which prevents them from seeking treatment, especially during the pandemic. It records the episode of psychological distress by using the patient’s end of Kleinman’s Explanatory Model of Illness and evaluates through inductive reflexive thematic analysis all the possible aspects that may be affecting the mental well-being of the individuals. The study utilizes content gathered through in-depth interviews of the 20 COVID recovered individuals at two COVID-19 treatment centers in the district of Sialkot, a government hospital, and a private healthcare facility. The results of the study suggest that COVID-19 has had a particularly negative impact on the mental health of individuals, leading to extreme psychological distress. Individual treatment-seeking behaviors are heavily influenced by multiple sociocultural and religious factors that restrict their treatment options. This study highlights the importance and needs to facilitate a system where individual experiences and perceptions coupled with medical treatment options are made available for the individuals.

According to the World Health Organization (2009) , mental health is more than the absence of any disease or disorder, it is exhibiting emotional and psychological well-being along with the ability to combat normal stresses of life with resilience. Psychological distress is defined as the condition of emotional turbulence, which is characterized by certain symptoms of depression (sadness, hopelessness, and isolation), and anxiety (constant fear, restlessness, panic) (Mirowsky & Ross, 2002 ). According to the WHO statistics, mental illnesses account for 4% of the total disease burden, with the rate of women being higher than men (Sareen, 2020 ).

The novel COVID-19 which emerged as an unknown case of severe pneumonia in Wuhan, China, soon took the world by storm, disrupting all aspects of life. The WHO declared it a global emergency in the form of a pandemic on 11th March 2020, based on its impact, the severity of the influence, and the ferociously increasing number of cases ( WHO, 2020 ).

The COVID-19 pandemic has had a profound effect on society, the economy, and vulnerable populations globally, acting as one of the most outrageous health crises. The social sphere is where these effects have become more apparent. Among the main effects are an alarming escalation of inequality and social fragility, disruption and disorder in social life and livelihood, and a marked decline in the quality and vitality of fundamental social indicators like mobility, social capital, and education (Alizadeh et al., 2023 ). The dynamics of social connections, political structures, and individual well-being are only a few of the societal factors that have been impacted by the pandemic (Uludag, 2022 ).

COVID-19 made people go through unprecedented consequences, the external chaos of the virus accompanied by economic, social, cultural, and financial burdens exhibited internally in the form of emotional turbulence causing psychological distress (Toulabi et al., 2021 ). A study conducted in the initial months of the outbreak showed alarming results. Among a sample of 1210 respondents, COVID-19 managed to severely impact a vast 54% of the participants. Twenty-nine percent showed moderate to severe symptoms of anxiety and depression prevalent among 1% of the target population (Cullen et al., 2020 ).

There have been deadly outbreaks synonymous with COVID-19, each leading to a scarred psychologically distressed population. According to a study conducted on the psychological impacts of the Ebola Virus disease epidemic, out of 116 survivors, 66% had post-traumatic stress disorder (PTSD), 53% had depression, 43% had anxiety, and 34% attempted suicide (Nyanfor & Xiao, 2016 ).

Pakistan, being a resource malnourished country became prey to the COVID-19 burden and its inevitable consequences. The people found themselves amid a disease outbreak with few resources and a weak healthcare structure to protect them. This situation had a grave impact on the residents’ already fragile mental health. Thus, the statistics on the psychological impacts of COVID-19 in Pakistan were alarming. In 2020, around 33% of the targeted people were suffering from depression, 27% from anxiety, and 48% were suffering from mild to moderate symptoms (Masroor et al., 2021 ).

Studies have shown a relatively higher occurrence of mental illnesses in Pakistan as compared to its Asian counterparts. Pakistan showed an alarmingly high 34% prevalence rate of anxiety and depression in 2020. As per the WHO Assessment Instrument for Mental Health Systems (WHO_AIMS; WHO, 2009), only 0.4% of the health spending is allocated to mental health in Pakistan. There are 3729 mental health facilities and only 5 hospitals dedicated to mental healthcare, which have 5056 beds and a total of 342 psychiatrists (Hashmi et al., 2020 ).

Pakistan’s mental healthcare system was already saturated when COVID-19 started to spread. There were huge spikes in anxiety cases in Pakistan, especially during the quarantine; it was observed that the patients faced feelings of helplessness, loneliness, and fear of death. There were multiple reports of people running away from the COVID centers, the main reason was the fear of being isolated (quarantined) (Khalid & Ali, 2020 ).

Mental illnesses in general are not a registered cultural norm in Pakistan. The culture of Pakistan gives little importance to nonphysical illnesses, and these are tagged as stigmas and taboos. Therefore, the people residing in these cultures are conditioned to negate any nontangible, not bodily visible illnesses. The social and cultural pressure also created a mind stretch in the people and further contributed to psychological distress. Religious and cultural coping mechanisms have been utilized for relief from distress (Zaman et al., 2021 ).

There is a significant treatment gap regarding mental health services available in Pakistan, with roughly one psychiatrist to a 0.5–1-million-person population ratio.  In Pakistan, mental health disorders cost the country $4.2 billion a year (Hameed et al., 2022 ). The impact of the COVID-19 pandemic on individuals' mental health was well recognized, and to assist those who were in need during the lockdown, the mental health telemedicine helpline was established. However, limited resources (psychiatrists and psychologists) were available for individuals who were seeking COVID-related treatment at the centers formed by the government (Farooq et al., 2020 ).

The impact of COVID-19 on psychological distress is significant. It has not only played a part in inculcating mental illnesses in individuals but has also triggered the already embedded mental health conditions. A survey conducted in the city of Wuhan in January 2020 showed that more than half of the people with COVID-19 complained of moderate to severe psychological symptoms (Khalid & Ali, 2020 ). COVID-19 acted as a stimulus for many individuals and triggered mental disorders. This resulted in feelings of hopelessness, depression, loneliness, fear, and guilt of survival. These symptoms were not controlled effectively and turned into psychiatric problems. This study aims to explore the perceptions and experiences of COVID recovered individuals regarding psychological distress, and the effects of COVID-19 on their mental health, which prevents them from seeking treatment, especially during the pandemic in a small resource less setting of district Sialkot, located in the outskirts of Punjab, Pakistan.

Conceptual Framework

The current study explored how individuals perceived, conceived, and defined psychological distress, especially during COVID-19, to comprehend the lived experiences of the individuals. The conceptual/theoretical framework utilized in this research was Kleinman’s explanatory model of illness. This is given by a renowned American psychiatrist and psychiatric anthropologist, Dr. Arthur Kleinman. The model works on the principle of understanding people’s illnesses as they understand themselves, keeping their cultural and personal perceptions in mind. This model better explains the cultural composition of sickness from the patient's perspective, as well as its understanding and management from the healer's perspective (Kleinman,1980). This study focuses on the patient's explanatory model of illness to investigate and document the illness episode and therapy from the patient's perspective.

Figure 1: Kleinman’s Explanatory Model of Illness

The model encapsulates four key arenas of etiology (the cause of the illness); time and mode of onset (when, where, and how the symptoms started appearing, as per their own opinion; pathophysiology (the functional/physical processes, that are related with the illness), as per the patient’s opinion; and course of illness and treatment.
 
Method

Research Approach

The study employed Interpretative Phenomenological Analysis (IPA), a qualitative approach that focuses on the thorough analysis of how individuals perceive and experience various life events.

Sample

After obtaining ethical approval from the faculities concerned, the individuals were selected from the patient’s treatment record that had undergone treatment and recovered from COVID-19. Healthcare workers serving in the two COVID centers were used to reach these patients. Two locales were selected for the data collection in the district of Sialkot: A government hospital and a private health facility, depending on the patient outflow in these facilities. Individuals were selected through a purposive (non-probabilistic) sampling technique. A total of 35 individuals were approached for the interviews, of which 20 agreed to participate in the study as per the inclusion and exclusion criteria.

The inclusion criterion for the individuals was their clinical diagnosis of psychological distress validated by a psychiatrist during COVID-19. They were diagnosed by practicing psychiatrists who were working in the two COVID centers located in the district of Sialkot, Punjab, Pakistan. These individuals were further screened through the K10 scale to ensure that their psychological distress ranged from moderate to severe (Kessler et al., 2002). On the other hand, respondents who were under 18 years of age and above 70 years were excluded from the study. Also, the people whose psychological distress ranged from mild to moderate on the K10 scale were excluded. The demographic profile of the respondents is given in Table 1.

Out of total participants, there is equal distribution of participants along COVID 19 Centre type that is public and private and also across gender that is male and female. Age range was 15-69 years.

Table 1: Demographic Profile of Respondents

 Interviews

The data was collected between the periods of April 2021 to June 2021 in which several prior visits were made to the target locations to distribute consent forms, while interviews were conducted during the later visits. In-depth interviews were used to extract data from the respondents. The interviews were conducted using an audio-recorder and a field journal, and each interview was manually coded for thematic analysis. The interview guide included broad domains such as mental health, psychological distress, social stigma, faith and spirituality, culture, and family. For instance, participants were asked questions like “What is mental health?” “What are the symptoms of psychological distress you have experienced?” “Have you faced any marginalization from the community?” and “How has your religion or spiritual path helped you during the COVID-19 pandemic?” The duration of the interview ranged from 30 to 50 minutes. The interviews were stopped once saturation was reached.

Procedure

In-depth interviews were conducted in bilingual (Urdu and English) language, depending on the comfort of the individuals. Before the interview, the objective and purpose of the research were shared with the respondents. The interviews were recorded through a mobile device with consent from the respondents. They were made sure that their confidentiality would be maintained and that the interview would solely be used for research. The respondents were questioned about their perceptions and experiences regarding psychological distress and the role of COVID-19 in enhancing or triggering any mental illnesses. The data gathered was transcribed and translated into English. The data were analyzed using the patients end of Kleinman’s explanatory model of illness.

Analysis

A reflexive thematic analysis was conducted, and relevant themes were drawn from the collected data. Coding was accomplished by combining fragments of text that were all about the same topic. Each theme comprised differing opinions of respondents belonging to the same category, that is COVID-19 recovered individuals who had suffered psychological imbalances during their treatment.  Themes and subthemes were later examined, amended, rejected, or substituted based on negotiations and comparisons with the original data set. A total of 39 codes were categorized, then separated into subthemes, and finally into five thematic areas. Important quotes from the respondents have been mentioned as verbatim in English to clarify and elaborate the theme. Pseudonyms have been used to keep individuals' privacy intact.

Results

The findings are presented in the context of Kleinman’s explanatory model of illness, which emphasizes how individuals and communities construct meanings around illness, its causes, and pathways to care. The themes emerging from the interviews were arranged to reflect this framework. First, participants’ meanings of psychological distress highlight how distress was perceived either as a myth or as a disruptive reality. Next, cultural perceptions and expressions and religious perspectives illustrate the explanatory factors shaping understandings of causation and appropriate responses. The role of family represents the social context influencing the course and management of distress, while decisions about treatment reflect the negotiation between personal suffering, cultural stigma, and acceptable pathways to care. This structure allows the findings to illustrate how illness experiences during COVID-19 were interpreted and acted upon within a culturally embedded explanatory model.

Meaning of Psychological Distress

Respondents had different ideas and opinions regarding what psychological distress was, and how it had a role to play in disturbing the daily life activities of the individuals. Some respondents thought that psychological distress was just a myth while others opined that psychological distress was real and disrupted one’s life completely if not treated. These perspectives were shaped by the cultural perceptions that have been inculcated in individuals; some challenge these perceptions while others follow them. Religion also has a key role to play in shaping ideologies, especially, related to psychological health as per the respondents.

According to a R4, “psychological distress is complicated to explain. I think that when you are in trouble then your mind is in an awful state. That is called psychological distress.”

Some respondents became familiar with psychological distress during the time of COVID-19. They acknowledged the fact that they did not think that psychological distress was anything real but now know what psychological distress is. As per R 9, if you asked me this before, I would not have been able to answer but after COVID, I have learned what it is. When your brain is under stress and cannot function properly then this is called psychological distress.”

Self-Diagnosis

Respondents in this study were asked about their observations regarding how it started, what were the reasons, and what exactly led them to psychological distress, especially during the pandemic. As per R 18, “I feel that it started when I was admitted to the hospital due to COVID. I started having palpitations, my heart used to be restless, and I had weird thoughts.”

Some respondents who already had mental illnesses, but these were never identified found out during the pandemic that the symptoms they thought were completely normal needed treatment. According to R13,
I used to have pain on my left side of the body, my hands used to sweat, my heart sank, and my hands shivered. When all these things happened in COVID then I got myself checked by the doctor. The doctor told me that I have an anxiety disorder.

Individuals started to suffer from psychological distress due to SOPs like home quarantine, lockdowns, social distancing, and the shutting down of all educational institutions. According to R7, “staying at home has made me feel worse than COVID itself. I have started having more depression. I feel that this time will not pass.”

Onset of Symptoms

Different respondents described different events during which they had the onset of their symptoms, but most of the onset of symptoms dated back to after getting diagnosed with COVID-19. Some did not experience the symptoms right after they suffered from COVID-19, and some got their symptoms right in the middle of their treatment. According to the data collected most of the respondents had no idea that these symptoms were of psychological distress. Many of the respondents ignored their physical symptoms assuming that they were the aftermath of COVID-19 according to R2, “when I had COVID, I started getting these (symptoms), so, I thought that they were part of the virus. That is why I did not pay much attention.”

Cultural Perceptions and Expressions
                                       
This theme focused on the cultural perceptions and expressions that formed the opinions of the respondents. The cultural setting in which the respondent resided played a significant role in understanding their answers as being part of a closely knit culture, they are subjected to certain stigmas, and their understanding of mental health is heavily influenced by the conceptions of their culture. Some of the expressions that the respondents mentioned were common among other respondents as well. There seemed to be a stimulus point for most of the respondents. The respondents seemed to externalize their internal experiences as Iss [it], Halaat [state], Ye [this], Wo [that], and Dimaghi [psychological/psychiatric].

Role of Culture in Psychological Distress

As per the respondents, culture played a pivotal role in spreading and triggering psychological distress. The symptoms that the respondents suffered from were expressed very similarly. For example, kandhay kechna [muscle stretching], rona [crying], dil doobna [heart sinking], hath kanpna [hand shivering], sans phoolna [panting], bayin hissay mein dard hona [pain on left side], dimagh ka sun hona [numbness of brain], thanday paseenay ana [cold sweats], gussa ana [anger issues]. These expressions are cultural. According to R16: “In our culture, practicing social distancing is a crime, I started meeting my neighbors with a mask, and they stopped talking to me saying that I have misbehaved with them. This made me so upset.”
According to the respondents, culture spreads a lot of misbeliefs as well. The gatherings played a role in spreading false or inaccurate news, which led to extreme psychological distress. According to R8,

I went to pray in the mosque, and there some people were talking about COVID that no one can recover from it, and it remains with you all life. I was very scared. When I contracted the virus, I felt like I would never survive this.
Some respondents opined that one should not challenge the culture as it is an important element in everyone’s life. It does not play a role in increasing psychological distress; in fact, it reduces stress and guides us to the right path. As per respondent R 19,
I don’t think there is any fault of culture, now this disease is here, and due to this, we are not able to go to mosques nor are we able to meet people. People do not understand that it will happen to anyone. This social distancing will not work.”

Culture: A Hurdle to Seeking Mental Health Treatment

According to the respondents, culture was the central component that became a hurdle in letting people seek treatment. The norms made by the culture restricted people from opening about their mental ailments and forced them to remain quiet. Thus, culture encompasses very prominent stigmas such as labeling, isolation, marginalization, etc. that became hindrances in seeking treatment. R5 said,

With great difficulty, I managed to find the courage to seek help. I was already stressed out due to my result. COVID made the situation much worse. When I talked to my parents about it, they started scolding me about what type of strange thing I was saying and how people would call me mad.”

Cultural Practices

The respondents opined that medical treatment and cultural practices go hand in hand but sometimes stand against each other. Culturally centric people prefer the cultural methods of treatment rather than spending money and time seeking medical advice. The role of Hakeem [traditional healer] is of prime importance in their society. R19 said, “I was getting relieved with healer’s medicine; my lungs became extremely unwell, so my children took me to the hospital.”

While some respondents opined that culture and science don't need to collide. One can follow cultural practices and still take medical treatment as well. “I feel that culture and science don’t have a war, I have taken medical treatment and drank ginger tea to fix my lungs. They should not be mixed. A person can be cultural and educated at the same time,”
as per R 4.

Role of Family in Psychological Distress

The respondents gave their opinions regarding the role of the family in handling psychological issues. As per the respondents, living in a closely-knit culture promotes dependency on decisions. The decision-making was not an individual process. The role of immediate family members was the determining factor in deciding between treatment-seeking options. Mental health was rarely discussed in the family as a topic, owing to this approach, talking about mental health, and then seeking treatment was a huge step that took a lot of convincing and sacrificing at the respondent’s end. Due to the pandemic, people spent more time with family members, they became a reason for relief as well as a reason for fear. According to one respondent R5, “Family is the biggest support during COVID. But when it comes to the psychological problem then family leaves your support.”

Pressure for Not Seeking Mental Health Treatment

When it came to seeking treatment, the process of convincing family members and support groups was immensely difficult. The culture that the respondents resided in had a very low understanding of mental health, and it was rare to be open about your illness and above all, seek treatment. People tended to look down upon individuals who showed the courage to seek treatment and stigmatized them as members of the culture. They were looked down upon and considered inferior and incapable. As per R 7, “it was very difficult to convince my family for treatment. Firstly, they were not ready to listen to me, and then when they saw my state, they realized that my depression has grown so much”.

The responses of the people confirmed the importance of the peer group in seeking psychological treatment. The results showed that most of the family members were not supportive and criticized the action of seeking treatment. It is noteworthy that the respondents used very similar cultural expressions to explain the reactions of the family members like gussa hogaye [got angry], chup honay ka bola [asked to remain quiet], taanay maray [teased].  As per one R 10,

I have always been scared to communicate about my state and symptoms to my parents. When I got COVID then my symptoms increased and became physical. One day I had a very bad panic attack, and I fell in front of my family when I gained consciousness, I told my parents everything. They did not support me at all and said that this is for the time being and I am thinking too much.

Religious Perspectives

The religious element as explained by the respondents had an exemplary role to play in the psychological distress perspective. On one hand, religion acted as a guiding stone and path for people to follow, and on the other hand, it restricted people from certain actions that were deemed sinful or unholy by the people. Psychological distress is not a widely discussed concept in religion as per the respondents. That is why it was mostly overlooked.  Instead of seeking treatment for psychological distress, other alternatives like witchcraft, wizardry, spiritual healing, and magic were preferred. This could be a cultural element as well, but it is inclined more toward the religious perspective because of the understanding and belief of people regarding psychological distress as a trial from God and wrath for disobedience. The respondents shared very detailed experiences of their lives and how religion triggered or provided relief from the pandemic.

Alternative Practices

Many respondents shared that during the period of their deteriorating health, they sought refuge in religious practices. Many even claimed that they were able to get out of this distress because of the religious practices and prayers that they followed. As per the respondents, they invested ample time in praying, crying for help from God, and reciting the Holy Quran and other verses. According to one R 9,

When I got psychological distress with COVID, then my grandmother gave me some verses to recite, I used to recite them every day, and to my disbelief, it did work for me. Not fully, but I used to feel at peace. Religion is the other name for hope.”

The respondents shared that another very important aspect that led them to alternative practices was the evil eye. The evil eye is a very popular phenomenon in many religions, and it is considered the main source of problems and distress among people. As per R 12,

You get affected with evil eye; people are jealous of you, of your successes, of your blessings. Today’s young kids do not believe in such things, but you do get affected by an evil eye.  It is all because of evil eye that I have become so sick.

Role of Spiritual Healers
                  
The respondents articulated that spiritual healers play a very integral part in the religious practices that people follow. The war between medical treatment and religion has been ongoing. Religious or spiritual healers have their place in one’s religion. As per some respondents, religious healing methods were way more effective than medical methods and also made them closer to God. As per R 10,

The moment my mother came to know that I was suffering from psychological distress, she went to her spiritual healer (Peer Baba) and brought an amulet for me, the healer calculated through his teachings that I possessed by some supernatural being.

As per one R 18, “I believe in my spiritual healer very much he told me to seek treatment. Not all spiritual healers need to be fake.”

Decision of Treatment

The respondents asserted that the decision of treatment for psychological distress was taken after passing through various stages of emotional and physical convincing. A person reaches this stage after immense self-convincing. Preparing oneself to seek psychological treatment in a society where mental health is disregarded and stigmatized was the most difficult decision as per respondents. The respondents shared their experiences regarding their process of deciding on treatment and how they handled internal and external stress.

Realization

The respondents shared their experiences of realizing that they needed treatment. The pandemic acted as a trigger for all the respondents who were already in psychological distress and others who had psychological distress due to COVID-19. The opinions from the respondents showed that the individual population is still divided when it comes to realizing that they need treatment, some realize it, but they face hurdles in convincing others, and some don’t realize that there is anything wrong with them. As per R5, “I don’t know about realizing, but when I came back after recovering from COVID, I felt if I didn’t go see a doctor (Psychiatrist), I would maybe commit suicide.”
According to R 4, “The most difficult phase is to realize that you are not well, you ignore this feeling, COVID helped me to realize that I needed psychological treatment, and I mustered up the courage.”

Family Pressure

According to the respondents, the real hurdle is not to convince oneself but to convince the family members that there is a need for treatment. The cultural perceptions made seeking treatment very difficult with family members following the cultural norms and disregarding the mental health of their loved ones. As per R5,

With great difficulty, I mustered the courage to seek help. I was already stressed out due to my result. COVID made the situation much worse. When I talked to my parents about it, they started scolding me and did not understand.

Seeking Help

Seeking help is the last step in the decision of treatment. After successfully convincing oneself and peers, the next step was seeking help from a professional. This process was also very tedious as there are not many psychiatrists in the town, according to the respondents. The number of psychiatrists and mental healthcare facilities made the cost of treatment huge for individuals, and this also became a hurdle in following up after starting the treatment. As per R18, “I seek psychiatric treatment but there are very less facilities here, there are only two hospitals in total in Sialkot, one is close to nonexistent, and the other is of the army.”

Table 2: Thematic Summary

Discussion

This study was aimed to explore the individual’s perceptions and experiences of psychological distress in the COVID-19 context. The findings of the study were divided into five core themes followed by their sub-themes. The results of the study highlighted the role of COVID-19 in triggering psychological distress among the respondents. Culture and religion proved to be pivotal influences in altering the treatment-seeking behavior and practices of the individuals. In addition to acting as coping mechanisms for psychological distress, sociocultural practices dominated healthcare-seeking decisions.
The findings indicate that participants’ understanding of psychological distress was deeply shaped by cultural and religious beliefs, which often contributed to stigma and delayed help-seeking. Family support emerged both as a protective and limiting factor, while decisions about treatment reflected a negotiation between personal suffering, cultural expectations, and socially acceptable remedies. Viewed through Kleinman’s explanatory model, these results highlight how meanings, causes, and pathways of care are constructed within a sociocultural context post the COVID-19 pandemic. The research used qualitative methodology, which proved to be effective in attaining the experiences and perceptions of people regarding mental illnesses, stigmas, and their experiences during the pandemic. Kleinman’s explanatory model encapsulates four key arenas etiology, time and mode of onset, pathophysiology, as per the patients’ opinions, and course of illness and treatment. These arenas aid in reflecting the individual and idiosyncratic experiences of the patients' journeys from the outset of their illness to treatment, as seen through their perspective. As the research subjects are COVID-recovered individuals, their perceptions were studied concerning the current pandemic.
As per the existing literature, etiology is defined as the factors that come together to cause a disease or an abnormal condition (Lauren, 2018). The respondents that were interviewed during the current study outlined mostly biomedical factors that led to their psychological distress. The main factor that triggered the cause of illness as per most of the respondents was their time of contracting the COVID-19 virus. However, they also stated other psychological, cultural, and economic factors that fueled and triggered their psychological distress; these stressors may be taken as social, cultural, and economic in nature. Kleinman’s explanatory model of illness contributed to finding and exploring the perceptions that people had of mental illnesses and the documentation of their experiences of psychological distress during the current pandemic. The respondents opined that the cause of their illness was related to their contracting the virus and the perceptions of society and culture regarding their illness. In addition to the above-mentioned, other causes highlighted were familial communicability, the tragic loss of a loved one, cultural factors like wizardry and witchcraft, and health and economic costs like increased prices of treatment, etc. The above observations confirmed the findings of the study conducted in the Northeast United States on Human Immunodeficiency Virus (HIV). The respondents of the study did not just term the cause of illness as natural or biomedical, they opined that the responsibility of contracting the illness laid on the patients, and the way they were transmitted was culturally and socially not widely an acceptable phenomenon even in the US (Laws, 2016).

The time and onset of the symptoms clinically are defined as the appearance of the symptoms of an illness for the first time. In the present study, the respondents had different onset and times of symptoms. On one hand, the time and onset of symptoms for most respondents were during the pandemic, specifically when they contracted the virus, after they recovered, during their quarantine period, while on the other hand, some respondents explained that their time and onset date back before the pandemic, such as genetic transfer, meaning a family history of psychological illness that made them more vulnerable to distress, and early childhood trauma, etc. This arena of Kleinman's explanatory model was also explored in another study conducted in the United Kingdom (UK) on Pashtun. A total of five Pashto-speaking families were interviewed to explore their health beliefs. The respondents from the five families explained that the time and mode of onset of symptoms in most of them was due to a sudden episode, rage, childhood trauma, etc. They also emphasized their moving to the UK as their time and onset of symptoms which showed that they did have an idea about the psychological impact of moving to the UK, which was causing psychological distress among them (Fazil et al., 2006).

Pathophysiology is defined as the functional/ physical processes, which are related to illness. The present study showcased the symptoms that were psychosocial and psychocultural, such as crying, isolating, cold sweats, heartburn, heavy sweating, shivering, headache, anger, loss of appetite, palpitation, muscle fatigue, etc. Kleinman's explanatory model of illness explained the perceptions of these respondents as per their understanding and beliefs of illness. According to a study conducted on maternal depression in Pakistan. Kleinman's explanatory model of illness was used to explain the pathophysiological behavior of maternal depression. The symptoms were mostly psychosocial and psychocultural, for example, muscle stiffness, crying, loss of appetite, exhaustion, sadness, difficulty in breathing, headaches, sleeplessness, anger, irritability, fear of the unknown, heart sinking, palpitations, etc. (Sakina et al., 2020).

The fourth arena is the course and treatment of the illness. The course of the illness is defined as the natural history, such as the development of the illness in an individual, the stages and speed of the process that the illness took, etc. As per the current study, the illness varied among respondents, while some respondents opined that their present psychological condition was a result of the pandemic and would be over with the pandemic, while on the other hand, some respondents gave a different perspective about their illness as being long term and demanding proper treatment. However, there was another dominant perspective which was ignorance and less emphasis on people's treatment. Rather than seeking proper treatment for psychological distress, they emphasized treating them with alternate methods. This is confirmed in the study about illness narratives of Pakistani women, in which the respondents sought to alternate methods that were cultural and religious rather than biomedical treatment methods (Sakina et al., 2020). The current study also demonstrated that one of the reasons for seeking alternative treatment was the health costs and financial instability of the individuals.

The treatment of the illness is attached to the course of the illness. In the present study, the treatment of the illness was a difficult hurdle. Psychological distress is a very new and emerging concept in the Pakistani society. Cultural and social barriers, like lack of awareness, social and emotional support, alternatives of treatments like witchcraft and wizardry, and religious beliefs come in the way of treatment as well as follow-up of the treatment. Cultural alternative treatments like going to the Hakeems [cultural healers] are preferred by the people because of their wide availability. Religion, culture, and mental health are broad domains that are interlinked. These discourses are studied separately, but very few studies are present that show the interlinkage of these broad categories. According to a study conducted by Eshun and Gurung (2009) a decade of literature present on religion, culture, and mental health showed that there was a negative relationship between religion and mental health; spiritually enlightened individuals were less prone to psychological distress.

Psychological distress is usually termed a non-specific medical condition, but studies have shown that psychological distress has its roots deeply engraved in the symptoms of depression and anxiety. This has raised concerns that psychological distress, if left untreated, will lead to long-term depression in the individual. Defining psychological distress as just a normal reaction to a stressor leads to increased concerns about challenging the norms of “normality” across different cultures (Drapeau et al., 2012). This study was confirmed by the present study. The respondents, through their conception and perception of psychological distress, showed that they had an idea about mental health and psychological distress. They were, if not completely but partially, aware of what psychological distress is and how it is stigmatized in society.

As per the researchers of the current study, South Asian communities have a distinct cultural arrangement. They are diverse and have multiple subcultures, which identify themselves differently owning to different ethnic factors (Mumtaz, 2021). Studies conducted in Pakistan have shown that the explanatory model of mental illness, the presence of social stigma, and alternatives of medical health like witchcraft and wizardry to mental health are unique among the people residing in these cultures (Noreen et al., 2020). Mental health problems for example panic, depression, anxiety, suicide, eating disorders, and various others are rarely discussed and talked openly about in society, beheld as a stigma by families as well as the community, and people turn a blind eye to their core presence, whether they relate to somatic causes and symptoms or non-somatic/psychological causes. This is particularly common in the case of individuals, who are extremely vulnerable to suffering from those mental diseases; this can be largely due to the cultural and social independence of the traditional society people foster.

Implications

This study highlights the importance and need for a combined approach that involves a combination of healthcare services and sociocultural and religious treatment-seeking practices to overcome the psychological distress caused by the COVID-19 pandemic. This study highlights that psychological distress in the community is not only experienced at an individual level, but is also interpreted through cultural beliefs, family influence, and religious perspectives. These findings suggest that interventions should move beyond a purely biomedical approach and incorporate culturally sensitive strategies that acknowledge stigma, spiritual beliefs, and family dynamics. Strengthening collaboration between mental health professionals, community leaders, and families could make treatment more acceptable and accessible. By aligning medical care with people’s explanatory models of illness, support systems can be designed that reduce stigma, encourage early help-seeking, and improve overall mental health outcomes.

Limitation and Suggestions

This study is limited by its reliance on self-reported experiences, which may be influenced by recall bias and personal interpretation. In addition, the sample was drawn from a specific cultural and geographical context, which may restrict the generalizability of the findings. Future research should expand to larger and more diverse populations, and consider mixed method approaches that combine qualitative insights with quantitative data to strengthen the evidence base.

Conclusion

This study is an attempt to explore the illness experiences of psychological distress faced by individuals in relation to COVID-19. Kleinman's explanatory model has been utilized to understand individual experiences as well as views and expressions of psychological distress in the face of a catastrophe. The findings of this study align with existing literature showing that cultural beliefs, family dynamics, and religious perspectives strongly shape how psychological distress is understood and managed. By situating these experiences within Kleinman’s explanatory model, the study contributes to raising awareness of individual perceptions and emphasizes the need for more accessible and culturally responsive treatment options.

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Received 16 June 2023
Revision received 23 February 2024