A qualitative type of study was conducted to get an insight into the stress among the frontline health workers. The study was associated with Nilratan Sircar Medical College and Hospital, Kolkata, India and it was done over a period of 12 weeks (April-June 2020) in urban primary health centres in the Kolkata corporation area. As the study was done in the middle of the peak COVID-19 period and lockdown, no official permission letter with IEC number could be obtained. Although the researchers obtained permission from Director of Medical Education, West Bengal, for team delegation to provide expert COVID-19 Guidance vide memo number DME/Special/Correspondence/2020/95 and Kolkata Corporation authority. FGD method was adopted in this study [6].

Inclusion criteria: Focus group participants were the community COVID-19 surveillance workers mainly comprised of “honorary health workers” and “100 days field workers”, employed in 5 different urban primary health centers in the Kolkata corporation area, chosen randomly from borough VI of Kolkata Municipal Corporation area, which was attached to the mother institution, NRS Medical College and Hospital. who were present on the day of study and gave the consent voluntarily, were included in the study.

Exclusion criteria: The health workers present on the day of the study but did not gave consent were excluded from the study.

A total of 55 participants or respondents formed the sample of the study. The central theme of the discussion was about the COVID-19 surveillance work related stress and their precipitating factors and the coping strategies.

The demographic survey included items related to age, sex, religion, educational qualification and their working experiences [Proforma-1]. Questions about the following topics were included in the Focus group script:

Total five FGD were conducted over a period of 12 weeks (April-June 2020) in urban primary health centres in the Kolkata corporation area. Each group consisted of frontline health workers working in the field service areas of urban primary health centres in the Kolkata corporation area and was conducted in five different urban primary health centres. Participants in those five urban primary health centres were 8, 10, 12, 10 and 15, respectively. So, a total of 55 participants were included in the study. Each session was led by a facilitator and conducted for a period of 90 minutes. Both the researchers had experience in both undergraduate and postgraduate medical teaching for more than a decade, in implementation of various national programmes at urban and rural field practice areas and long experience of conducting FGDs in different areas. During FGD, each participant was assigned a code number and their word-to-word conversation was transcribed. Researchers took notes of the conversation verbatim during the session. Confidentiality was ensured and no editing was done. Their conversation was also recorded by hand-held mobile recorder and verbatim transcript was completed after proofreading. Debriefing was done following the session and professional help was offered if required. Notes were independently reviewed by the researchers and the themes were identified. The inter-rater reliability was ascertained by a senior faculty member of the department of Community Medicine, in the form of triangulation and reported a concordance of around 85%. Personal protection, adequate sanitisation and social distancing were maintained during data collection. Data was then summarised and analysed qualitatively. In the analysis of data, main themes were identified by investigating the ideas and compiling them together.

Descriptive statistics were used for calculating frequency(n) and percentages (%) from the collected data.

Participants of the FGD belonged to the age group of 21-55 years. Most of the participants, 37 (67.28%) belonged to the age group of 30-50 years, 38 (69.10%) were females, 33 (60%) followed Hindu religion and 36 (65.45%) were educated up to secondary level of education. Majority of the participants, 47 (85.46%) were temporarily appointed by KMC on contractual basis, 37 (67.27%) had 5-15 years of experience and only 8 (14.54%) were formally trained for the surveillance activity [Table/Fig-1].

Participants of the focus groups mentioned positive aspects of this surveillance activity in the following ways:

Participants expressed about the stressful situation related to the surveillance activity. Residents were afraid of spread of the virus by the health workers themselves. Those health workers, who were residents of the local service area, were even ostracised because of their profession.

“Neighbours even avoided our shadow. They didn’t even allow us to go to the local grocery shop because of fear of the virus”, said one participant. Discrimination of health personnel by the society caused mental stress and strain.

People were afraid of the Personal Protective Equipment (PPE) clad health workers during the house-to-house surveillance activities. Local residents even complained against them as they tried to identify the ILI and SARI cases in the community. Some of the health workers in two health centres mentioned “the local people surrounded us and were very much agitated. They even threatened to assault us if we continue with the surveillance activities. Hence, we were very scared.”

The community feared about getting quarantined at an institution by administration if they complained of fever. Thus, there was under-reporting of fever cases as people tried to suppress their health status. This affected the health worker’s performance of surveillance activities. Residents misbehaved and even attacked the health worker while they were on their duties. They even had to bear the brunt of the miscommunication during patient referral. This caused mental stress and strain. One health worker said," I identified a SARI case during a visit but his relatives denied. When patients condition deteriorated, they agreed to admit the patient after repeated counseling. But unfortunately, he couldn’t be admitted due to lack of vacant bed. Now patient party started to misbehave with us as we could not get him admitted. But we were at loss as we did not have access to those hospitals.

There was an inadequate supply of resources of PPE. Thus, measures of personal protection might have been compromised. Surveillance workers were also scared for their own family members who might have been getting the infection from them. Safety of their family members was also causing them mental stress. “The stress is unbearable” was the response obtained from most of the participants. Another participant said, “I would blame myself if any of my family members becomes infected with corona virus infection.”

Precipitating factors for the mental stress were several. But important factors were both physical and verbal abuse by the community, unfriendly attitude of some of the relatives and neighbours, continuous rise of COVID-19 positive cases along with the inadequate supply of PPE resulting in the fear of getting infected, and informal training of the surveillance workers. Inspite of these stressors, they tried to cope with the situation.

Surveillance workers tried to relieve their stress by discussing about their problems among themselves and also with the medical officers posted in the urban primary health centres. They also sought help from local administrative authority, local councilor and local religious leaders for conducting surveillance activities successfully in the community. Most of the surveillance workers were informally trained thus they sought help for formal training for surveillance activity.

In the present study, FGD were conducted to explore the perceptions of stress related trigger factors and coping strategies among the community COVID-19 surveillance workers and the main themes emerging from them were assessed qualitatively.

The present study elicited service to society during pandemic and income generation as most important positive aspects of job, as mentioned by frontline health workers. This was similarly elicited by Zhan M et al., found financial aid and professional opportunities were the most important factors for positive aspect of job [7]. Liu Q et al., reported professional commitment as an important motivational factor [8].

A study in Bangladesh by Absar MN and Rahman MH, on the patients awaiting medical assistance in the district hospital and a medical college found that beneficiaries expected to avail medical help in need, appropriate management and adequate emergency care services. Expectation of confidentiality also played a vital role [9]. This was also found in the present study about patient’s expectation regarding complete medical care including personal care.

Giorgi G et al., found that general public including professionals were exposed to stress during the current COVID-19 pandemic. Health care workers including health workers were overburdened with significant professional stress during current COVID-19 pandemic [10]. Vizheh M et al., in their systematic review also presented similar findings. The doctors, nurses and all the frontline workers showed symptoms of psychological disorder especially in younger age groups and from areas with high infection rates [11]. The present study unveiled the problem of the social stigmatisation as complained by the health workers. They raised the issues of untouchability by people from the society. Stigmatisation might be due to fear about getting infected by the health workers [12-14].

The present study revealed that the local residents did not cooperate with the health workers during surveillance activity because of fear of getting quarantined. The health care workers remained pre-occupied with the fear of contracting infection and spreading it to their family members, negative publicity of the media and non-cooperation of the general public.

Krystal JH reported that during COVID-19 pandemic health care workers were pre-occupied with the risk of getting infected with COVID-19 infection, work related anxiety, avoidance of health care setting, impulsive attention to COVID-19 related information through various media, anxiety, depression etc. However, most of them recovered but if not then this led to burnout and functional impairment [15]. Stigmatisation of illness was observed in case of Human Immunodeficiency Virus (HIV) related illness along with other layers of stigma like race, gender, drug abuse and polygamous relationship etc. Stigma influenced behaviour change. Thus, it prevents early health care seeking for diagnosis and treatment [16]. Similar kind of stigmatisation also observed in the present study where people were afraid of getting discriminated if they contracted COVID-19. Because of this fear they avoided to report ILI and even SARI cases. This under-reporting, halted identification of ILI and SARI cases and prevent early reporting of suspected COVID-19 cases which was necessary to contain the pandemic. Surveillance workers faced aggression from the society while they were performing their duties. Similar kinds of aggressive behaviour against health care professionals were observed throughout the country during the COVID-19 pandemic, even during the contact tracing and screening of ILI and SARI cases [17]. During the pandemic, attack on health care workers ranged from verbal abuse, threats to aggressive gestures, manhandling, abduction and even murder. These attacks on health workers were due to ignorance about COVID-19 infection, inadequate knowledge about natural history of disease, undue fear regarding getting quarantined. It was further exaggerated by imposed lockdown, transport suspension leading to inability to access healthcare centre and misinformation by various social media [18]. Munawar K et al., reported that negative publicity in various media elevated the stress and anxiety level among general public [19]. The various print, audio-visual and social media should be mobilised to highlight the positive actions of different members of society including the frontline workers in this pandemic situation and alleviate unnecessary apprehension among the members of the community [20].

The present study revealed that the surveillance workers tried to relieve their stress by discussing their stress related issues among themselves and also with the medical officers posted in the urban primary health centres. They also communicated with local administrative authority, local councilor and local religious leaders for conducting surveillance activities successfully in the community.

Liu Q et al., reported that health care providers pointed out several sources of social support and applied various self-management strategies to cope with the stressful situation [8]. Previous study by Munawar K and Choudhry FR, showed that avoiding media reports, limiting the sharing of information regarding duties performed with family members and religious faith were some of the major coping strategies adopted by the health care workers [19]. Anwar A found that social media usage had increased several folds following lockdown during COVID-19 pandemic. Provision of mental health education through social media was also initiated during COVID-19 pandemic [21]. Here mass media can play a vital role in generating awareness instead of spreading misconception about disease.

Details of opinions and perceptions of each study participant could not be elicited and hence individualistic in-depth analysis could not be done. It was time consuming and not statistically representative. Causality could not be ascertained by this method.

In the recent situation of COVID-19 pandemic, contact tracing and community surveillance are of utmost importance. It can be concluded from the present study that though the frontline health care workers took pride in getting involved in the surveillance work, almost all of them expressed apprehension against social stigmatisation, verbal and possible physical abuse. The need for formal training in surveillance under the current pandemic situation was also elicited and thus recommended. If healthcare workers face resistance during their surveillance activities then control of pandemic would be held back. Enforcement of “Epidemic disease Act”, investigation and commencing appropriate legal proceedings against offences could improve work place environment and thus ensuring containment of pandemic reduce and promote community participation in the fight against the pandemic. It is recommended that similar FGD might be carried out in future to explore the community perception of the basis of stigmatisation and the ways to overcome it.