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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 71-76

Experiences of quarantine for individuals during the COVID-19 outbreak in Kashmir: A qualitative study


Ph.D. Research Scholar, Department of Social Work, University of Kashmir, Srinagar, Jammu and Kashmir, India

Date of Submission16-Jul-2020
Date of Decision20-Jul-2020
Date of Acceptance27-Jul-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Mr. Zahid Maqbool
House No, 1D, Budshah Nagar Opposite Iram Lane, Natipora Srinagar - 190 015, Jammu and Kashmir
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_206_20

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  Abstract 


Context: The coronavirus disease 2019 (COVID-19) outbreak originally occurred from Wuhan, China, in December 2019 and gradually spread to other countries in different parts of the world. The COVID-19 outbreak has led many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in administrative quarantine facilities. Thus, quarantine at different levels, from individual to community, was seen as an effective measure of preventing the spread of this disease. Aims: The aim of the present study is to explore the experiences of quarantine for individuals returning from Bangladesh during the COVID-19 outbreak in Kashmir. Settings and Design: This study follows qualitative narrative design. Subjects and Methods: This study used an in-depth, semi-structured interview guide. Purposive sampling technique was used to select the participants who varied in terms of gender and age. Results: Despite individual differences, the experiences narrated by participants followed stages beginning before, during, and after ending the quarantine. The government authorities adopted a policy of mandatory quarantine to all the incoming passengers with the aim of preventing the spread of this pandemic. However, participants reported facing several issues such as shock and fear, feeling of isolation and loneliness, frustration and boredom, and loss of routine activities during this period. Conclusions: Quarantine as a method of preventing transmission of severe disease outbreak should be carefully used after effectively weighing its potential benefits and risks. The results of the study can be used to devise a proper policy framework and practice for effectively managing future quarantine and isolation-related health emergencies.

Keywords: Administrative quarantine, coronavirus, public health policy, quarantine experience


How to cite this article:
Maqbool Z. Experiences of quarantine for individuals during the COVID-19 outbreak in Kashmir: A qualitative study. Indian J Soc Psychiatry 2021;37:71-6

How to cite this URL:
Maqbool Z. Experiences of quarantine for individuals during the COVID-19 outbreak in Kashmir: A qualitative study. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:71-6. Available from: https://www.indjsp.org/text.asp?2021/37/1/71/312868




  Background/Introduction Top


Quarantine is the separation and restriction of movement of people who have potentially been exposed to a contagious disease to ascertain if they become unwell, so reducing the risk of them infecting others.[1] Quarantine is different from isolation, which refers to the separation of people who have been diagnosed with a contagious disease from people who are not sick. Thus, quarantine is for those with no signs or symptoms who have possibly been exposed to a contagious disease and have the potential to transmit the disease to others. If an individual is potentially exposed but asymptomatic, this person may be subject to quarantine. Once the individual becomes symptomatic, quarantine would no longer apply and the person should be isolated. However, the two terms are often used interchangeably.[2] Experts trace the origin of quarantine as far back as the Old Testament purity laws.[3]

The term quarantine comes from the Italian quarantina, a period of 40 days, derived from quaranta, the Italian for “forty.” It refers to the 40-day segregation of ships during the plague.[4],[5] It was first used in Venice, Italy, in 1127 with regard to leprosy and was widely used in response to the Black Death, although it was not until 300 years later that the UK properly began to impose quarantine in response to plague.[6] Recently, quarantine has been used in the coronavirus disease 2019 (COVID–19) outbreak. As a result of this outbreak, all the cities in China have been effectively placed under mass quarantine, while as thousands of foreign nationals returning back home from China have been asked to self-isolate at home or in state-run facilities.[7] It is worth mentioning that quarantine has been used earlier as well, with citywide quarantines being imposed in areas of China and Canada during the 2003 outbreak of severe acute respiratory syndrome. In addition, all villages in most of the West African countries were put under quarantine during the 2014 Ebola outbreak.

Quarantine is often an unpleasant experience for those who undergo it. Issues such as separation from loved ones, the loss of freedom, uncertainty over disease status, and boredom can, on occasion, create dramatic effects.[8] Suicide has been reported,[9] substantial anger has been generated, and lawsuits were brought[10] following the imposition of quarantine in previous outbreaks. The potential benefits of mandatory mass quarantine need to be weighed carefully against the possible psychological costs.[11]

Research studies on the effects of quarantine on individuals living in the community are very less. The main problems faced by the individuals who were quarantined in Toronto were emotional difficulties and loss of income, according to one quantitative study.[12] In another study, approximately one-third of the respondents to a web survey about quarantine reported symptoms of depression or posttraumatic stress disorder.[13] Although several studies have been done on the effect of quarantine on the people and their experiences, yet they provide limited insight due to individual factors and social situations.

The individual experiences of individuals on quarantine may be quite unique and as yet remain unexplored. Understanding these experiences is crucial in order for public health officials to design health emergency plans that are responsive to the unique life situations of the individuals who will be most effected by them. Knowledge of the problems/issues experienced by individuals in quarantine may indicate areas requiring further study to determine the roadmap for public health services. Thus, the purpose of this qualitative study was to explore the experience of quarantine during the COVID-19 outbreak in Kashmir. This will help us to understand the issues of the people under quarantine, thereby assisting authorities in framing appropriate policies and actions in places that are enforcing quarantine for returning citizens.


  Subjects and Methods Top


As few studies exist about the experience of quarantine, a narrative qualitative design was selected in order to understand their experiences through their stories.[14] Purposive sampling technique was utilized for data collection. Before initiating the study, proper consent of the participants was obtained and they were introduced about the purpose, potential risks, confidentiality, and goals of the study. Ethical approval was also sought from the ethical committee of the department of social work. Besides, approval from the government authorities was also sought prior to the conduct of study.

The total number of individuals in the quarantine facility was 65: 40 (62%) were female and 25 (38%) were male. All the individuals were given the equal opportunity to participate in the study, however only 15 individuals showed interest. Only the interested individuals (15) who were representative of the wider group held in quarantine were interviewed. The Interviews took place after spending the 14 days (March 24, to April 6, 2020) quarantine period at the designated government-run facility in Srinagar (capital city of Kashmir). Each interview lasted approximately 1–2 h. All the interviews were audiotaped and followed a semi-structured interview guide. All the participants were requested to describe their experiences of quarantine in detail.

Sample

The sample size of the individuals who participated in the study was 15, which included 9 females and 6 males. They were in the age group of 19–24 years. The interviews continued till there was saturation of data and no new additional information was coming up. All of them were placed in quarantine on March 24, 2020, for a period of 14 days. It was a hotel-turned quarantine facility for individuals returning from outside India, in the outskirts of Srinagar city.

All the participants were students who were studying in Bangladesh but returned back to India after the outbreak of COVID-19. Upon their arrival on the Srinagar Airport, they were examined by the doctors and after being found asymptomatic were sent to quarantine facility as a precautionary measure.

Data analysis

Interviews were transcribed verbatim and used as the primary source of data. The interviews were analyzed using categorical-content perspective.[15] The material was read several times to obtain an understanding of the whole and patterns. The next step consisted of grouping the quotes of each participant based on similarity of content. Then, the grouped quotes were compared and similar subthemes were identified. Then, the subthemes were grouped into larger categories, identified as themes. Based on the themes, general categories were constructed.


  Results Top


During the interviews, the participants were asked to describe their experience while in administrative quarantine. The experiences of quarantine were profound and had an adverse impact on their psychosocial and mental health besides affecting their routine activities. However, it was found that not only the actual period of undergoing quarantine, the period before and after quarantine also was a unique experience. “Before-” quarantine experience evoked uncertainty, fear, and shock among the participants due to various reasons, whereas “after-” quarantine experience generated feeling of happiness, relief, and sense of control. Thus, when the interviews were analyzed, three categories with several themes and subthemes emerged from the study: life before, during, and after quarantine, with major focus on “during-” quarantine experience. The boundaries between categories were fluid and flexible because of the complexity of the experiences of quarantine. Uncertainty, for example, was intrinsically intertwined with other subthemes, as it would often result in a feeling of loneliness and stress. Similarly, the experiences “before” the quarantine shaped the experiences during the “quarantine.” Thus, the three stages were interlinked to each other.

Life before quarantine

This phase captures the experiences of participants before they were ordered to undergo administrative quarantine. The expectations and fears of being quarantined shaped the actual experiences of quarantine. Three subthemes were identified within this category.

Shock

Most of the participants indicated that they were shocked to hear about being quarantined that too in an administrative quarantine facility.

I heard the news at the airport and felt shocked about being quarantined that too at a government designated facility. I was also shocked to hear that I will be quarantined since I was asymptomatic and had cleared the medical tests at the airport itself. I literally cried and was very fearful of the idea of being quarantined.

Fear

The participants were fearful of the things that might unfold during the period of quarantine.

I had no prior experience of quarantine so I was very afraid of the forthcoming experiences like facilities, resource persons, health check-ups, food etc., that made me anxious.

Uncertainty

Several participants narrated that they had a feeling of uncertainty about what is going to happen to them in quarantine, which created a feeling of anxiety.

I was unsure about what was going to happen to me. I was skeptical about the facilities at the quarantine facility. Besides the duration, nature and treatment were other things I was uncertain about and this made me anxious and worried. The authorities also did not provide information and reassurances to allay fears and uncertainty.

Experiences during quarantine

The participants narrated emotional responses after being quarantined. During this phase, the following six subthemes emerged: feeling of isolation and loneliness, feeling stigmatized, frustration and boredom, inadequate information, loss of academic activity, and difficulties in sleep.

Feeling of isolation and loneliness

The participants experienced feeling of isolation and loneliness as they had limited contact with their social circle such as family, friends, and relatives. Besides, the inmates were not allowed to physically meet each other.

We were segregated and allotted separate rooms for our stay. We could not physically talk to each other nor come out of our rooms. This created a sense of loneliness.

Feeling stigmatized

Many participants reported the feeling of stigmatization as they traveled from Bangladesh that was also one of the COVID-19-affected countries. Besides, few participants also reported being blamed for bringing the virus here and being the potential source of infection.

One participant reported the feeling of stigma and blame as,

I felt awkward as people were avoiding and staying away from me. I could sense myself being considered as a potential cause of infection but at the same time I was afraid of contracting the disease myself. I was scared and felt anxious.

Frustration and boredom

The participants reported frustration and boredom as the consequences of quarantine. This was due to loss of usual routine, reduced physical and social contact with others, lack of productive/meaningful activities, and nonprovision of entertainment avenues during their stay.

One participant reported boredom due to absence of any meaningful activity to pursue:

I sat in my room all the time thinking, worrying and being bored without anything meaningful to do.

Another participant reported lack of high-speed internet connection as the cause of boredom:

I sat in my room all the time and was not allowed to come out and interact with other inmates. Besides I could not even keep myself updated about the latest happenings of the Covid-19 due to low speed (2G) Internet connectivity. Entertainment through surfing Internet was a rare thing for me as it took years to load or download a video. This resulted in frustration, stress and a sense of agitation that resulted in problems of falling asleep.

Inadequate information

Most participants reported lack of information and awareness of the recent happenings, particularly with regard to COVID-19. Insufficient clear guidelines about the actions to take and confusion about the purpose of quarantine were reported. This was due to two man reasons: first, due to low-speed internet (2G) connection which made it very difficult for participants to access newspapers, journals, and websites, providing quality and reliable information about this deadly disease. This was more important as the research on COVID-19 was going on with new results, precautions, possible source of infections and do's and don'ts, and the global burden of disease emerging on a daily basis. Second, due to nonavailability of timely information from the authorities about the latest happenings around the world, which created stress. This created a sense of lack of transparency from the health and government authorities about the magnitude and nature of this disease.

I considered myself living in a cave isolated from the rest of the world with no knowledge about the world events. I guess high-speed Internet connection could have made the difference and kept me upto-date about the recent developments.

Loss of academic activity

The participants were students studying in different colleges of Bangladesh and had returned back due to COVID-19. From the day of the outbreak of the disease to the day they were quarantined here, they had lost touch with books and hardly pursued academic activities. This subtheme is not strictly limited to this phase only rather it goes to the previous stage and extends to the next stage as well. However, during this stage, loss of studies/academic activity was more prominent.

One participant expressed this as:

Since the day I left from Bangladesh I have not touched my books that has resulted in intellectual isolation in me. I fear about losing my interest and securing fewer grades, which is making me worried.

However, it was also revealed that they received support from the doctors from time to time in terms of medical checkup, information about the current happenings, assurances, and counseling, which to some extent reduced their stress and anxiety.

Difficulty in sleep

Some participants also cited difficulty in feeling asleep as the consequence of quarantine. The reason narrated was anxiety and persistent state of worry and thinking.

I prepare the bed, switch off the lights but still find it very difficult to sleep perhaps my mind isn't relaxed and keeps on thinking about the entire happenings. At last when I fell asleep its duration and quality has deteriorated.

Experiences after quarantine

This stage depicts the end of quarantine period and resumption of normal activities. Two subthemes emerged during this stage: happiness and relief and sense of control.

Happiness and relief

This was the collective reaction of the participants after being released from the quarantine. One participant indicated:

I was on cloud nine after being released from here. My happiness was beyond words as I could now meet my parents and siblings after a long time. I felt like being released from a prison. Finally there was a feeling of normalcy in my life and I was free.

Sense of control

The participants reported a sense of control over their lives after being allowed to go home. One participant reported

Now I can live my life as per my wishes without being told what to do and what not to do. I feel so empowered being able to take my own decisions.

Another participant expressed:

I am not being controlled and subjected to follow instructions and rules, so there is a feeling of normalcy and a sense of being myself.

Some participants described behavioral changes such as the habit of washing hands, wearing masks, and avoiding gatherings, as a result of quarantine.

It is worthwhile to note that most of the participants reported satisfaction with the facilities provided in terms of food, washrooms, bedding, and overall hygiene. However, during the initial days of quarantine, they faced some problems that were rectified during the course of time. The participants appreciated the efforts of doctors for their relentless and untiring efforts in terms of medical checkup, counseling and emotional support, and timely information and educating about the do's and don'ts of COVID-19.

Besides, they underwent another medical checkup at the time of leaving the quarantine facility and were subsequently directed by the doctors to undergo home quarantine and avoid meeting people and follow standard hygiene practices.


  Discussion Top


Quarantine can be a necessary preventive measure during the outbreak of a major infectious disease outbreak. The purpose of this study was to explore the experiences of participants who were quarantined in an administrative facility. Each participant had a unique experience of quarantine due to their individual differences such as the personal qualities and the experience of COVID-19 before quarantine. The information of being quarantined aroused feelings of shock, fear, and uncertainty that were further aggravated by the experience of isolation. The experiences “during” the quarantine period were problematic, were more intense, and were challenging for the participants than the before- and after-quarantine experience.

The results of this article in terms of isolation and loneliness are consistent with the existing literature that reported a high burden of mental health conditions among individuals who experienced isolation or quarantine.[16],[17],[18] Gammon et al. found that 33% of the participants who had undergone source isolation had poor mental health status.[16] Among specific mental health outcomes, all reviews reported a high prevalence of anxiety among the study participants.[16],[17],[18],[19],[20],[21],[22],[23]

Fear[24],[25],[26],[27],[28],[29] and stigma,[30] as experienced by the quarantined participants, were reported in some studies, which impacted their mental health and well-being.

Lack of adequate information about the guidelines and actions to be taken as highlighted in this article is consistent with the results of various studies.[24],[25],[26],[27],[28],[30],[31] This nonavailability of information created confusion and led to anxiety and stress among the participants.

Anxiety induced-insomnia[29],[30] as reported by the participants also highlights the adverse consequences of quarantine. The participants reported lack of energy and concentration levels during the day as the possible outcome of insomnia.

Frustration and boredom[12],[13],[25],[26],[27],[31],[32],[33] were also reported as the consequences of quarantine, consistent with the findings of several research studies.

Participants, as all of them were students, reported loss of academic activity that aroused a feeling of stress about getting low grades in the forthcoming exams. The authorities could have facilitated these students with the availability of books and online educational platform where they could have access to reading materials. This could have kept them engaged and at the same time reduced their stress.[17],[28]

Quarantine period also meant disruption in the daily routine activities,[13] which led to irritability and low mood[34] among the participants. It has been observed that the disruption of normal daily activities is potentially stressful and anxiety provoking. Similarly, feeling of happiness and relief as found in this article is consistent with the results of the study.[35]

It was found during the study that the role of doctors and administration becomes very crucial during quarantine. Regular health checkups, counseling, emotional support, and dissemination of timely information can go a long way in reducing the adverse impact of quarantine.

While the sample was broad enough to explore the range of experiences, these findings may not apply to all individuals in quarantine. Besides, the participants in this study were students, hence the findings may not be generalizable to the general population. Limitations of the study include predominance of female students, a specific age group, and a small sample size.

This study was an attempt to improve our understanding of the subjective experiences of quarantine, thereby assisting authorities in framing appropriate policies and actions in places that are enforcing quarantine for returning citizens. The themes identified during this study can be further studied to check their relevance to a larger and more diverse sample, which will help in shaping better policies for handling such outbreak in future. Additional research will further highlight and prioritize the issues that require attention by stakeholders concerned with the effective management of infectious disease outbreaks in future. Successful use of quarantine as a public health measure requires to reduce, as far as possible, the negative effects associated with it while at the same time to derive maximum benefits so as to prevent the transmission of infectious diseases.

Recommendations

  1. People with preexisting poor mental health would need extra support during quarantine, hence special care should be provided to such individuals. The focus should be on integrating psycho-social care and mental health support alongside physical health services during quarantine or isolation for infection control
  2. Authorities should focus on reducing the boredom and improving the communication network. People in quarantine should be provided with mobile phones, chargers and secured electricity connection, and a robust Wi-Fi network with internet access to allow them to communicate directly with their loved ones. This could go a long way in reducing feelings of isolation, stress, and panic
  3. Public health officials should provide adequate information so that those under quarantine have a good understanding of the disease in question and the reasons for quarantine. Besides, they should maintain clear lines of communication with people quarantined about what to do if they experience any symptoms
  4. Interpersonal relationships, networks, and social capital appear to have critical significance during major health events, including quarantine and isolation. Such ties must be identified and leveraged to improve mental health outcomes
  5. Adequate workforce of trained staff (doctors, psychiatrists, counselors, psychiatric nurses, housekeeping etc.) will go a long way in addressing the psycho-social issues of such people in an effective and time-bound manner
  6. A telephone support line, staffed by psychiatric nurses, set up for those in quarantine could be effective in terms of providing them with a social network
  7. The quarantine period should be kept minimal and decided in advance as it has been seen that longer quarantine is associated with poorer psychological outcomes
  8. There should be adequate availability of supplies for their basic needs and well-laid plans for its replenishment as and when they run out.


Acknowledgment

The author wishes to thank the study participants for their contribution, as without them it was not possible to undertake and complete the article. The author is also thankful to the health and government authorities for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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