Exploring Mental Health and Psychosocial Well-Being in Recovered Jordanian Individuals With COVID-19: A Phenomenological Study

ABSTRACT Background COVID-19-related healthcare services focus primarily on medical and physical treatments. Related treatments for psychosocial and mental health needs have not been a priority for healthcare professionals. Understanding the process by which individuals who have recovered from COVID-19 adapt psychologically will allow better planning for mental healthcare and healthcare outcomes. Purpose The purpose of this study was to explore how recovered individuals with COVID-19 adapted to related psychological and social stressors during the infection period. Methods A descriptive phenomenological approach was used to investigate a purposive sample of 13 individuals in Jordan who had recovered from COVID-19. Data were collected using semistructured interviews. Results Perceptions related to being diagnosed with COVID-19 were distinguished into four major themes: conscious awareness (acceptance, victimization, and normalizing), uncertainty (apprehension and poor communication), sources of psychosocial support (caring family, healthcare professionals' support, and self-grieving), and resilience (optimism, positive thinking, and spirituality). Conclusions The findings of this study indicate the need to integrate psychosocial and mental healthcare services into healthcare plans provided to individuals with COVID-19 and similar pandemic infections.


Introduction
The recent focus of healthcare systems and professionals has been on eliminating and controlling the adverse consequences of COVID-19, whereas the mental health status of individuals who have recovered from COVID-19 has received little attention . The World Health Organization (2020) has recommended prioritizing the mental health and psychosocial support needs of individuals diagnosed with COVID-19. The results of studies indicate that individuals with COVID-19 experience related mental health problems and that healthcare professionals are not sufficiently competent to provide the mental healthcare services needed Li et al., 2020). In a recent study, healthcare professionals were found to have inadequate knowledge about the mental health priorities and needs of individuals with COVID-19 and to lack the skills necessary to manage these needs (AlShibi & Hamdan-Mansour, 2020;Hamdan Mansour et al., 2020). One significant concern is how individuals with COVID-19 have adapted psychologically to health quarantine measures and responded to media and social pressures, given that mental health is not sufficiently emphasized in treatment plans and protocols.
The Ministry of Health in Jordan reported on July 15, 2022, a total of 1,700,528 confirmed cases of COVID-19 and 14,068 related deaths (Ministry of Health, 2022). Individuals suspected of having or infected with COVID-19 are subject to strict rules of quarantine that may negatively impact psychological well-being. This is in line with recent reports that quarantined individuals worldwide have experienced increased levels of anxiety, depression, and psychological distress (Hamaideh et al., 2022;Liebrenz et al., 2020). In particular, individuals with COVID-19 are reported to face higher risks of emotional and cognitive disturbances (AlAzzam et al., 2021;Li et al., 2020). Many factors contribute to increased panic within a general population and increased uncertainty in patients with confirmed COVID-19 infections.
For example, the term "pandemic" has been found to exacerbate anxiety as well as compulsive thinking and behaviors in many countries around the world . Anxiety has also increased in many countries because of media and other reports of shortages in medical supplies Huang & Zhao, 2020). Individuals who have recovered from COVID-19 may experience guilt and grief because of the loss of loved ones or from being accused of spreading the infection to others, including family members (Liebrenz et al., 2020).
According to a recent study, Jordanian health workers and ordinary people with confirmed COVID-19 infections have faced social discrimination (Dalky et al., 2020). Although the mental health of individuals with COVID-19 has been addressed in recent studies, most are quantitative and use electronic and online formats to measure and assess mental health problems. Recently, studies have shown that participation in sports improves psychological adaptation in athletes and that psychological adaptation and recovery from psychological distress has been at an average level because of the COVID-19 pandemic (Abu Mansour & Abu Shosha, 2022;Daly & Robinson, 2021;Rubio et al., 2021).
The literature indicates individuals with COVID-19 are seriously injured both physically and mentally because of the disease process and its consequences Huang & Zhao, 2020). Nevertheless, how traumatic that experience was and how they managed requires further investigation, with a qualitative approach necessary for a better understanding. Using a descriptive phenomenological qualitative approach provides insight into the lived experiences of recovered individuals with COVID-19 using their own narratives and descriptions of their experiences. Examining the lived experience of these people and addressing their psychological adaptation and sources of psychological and social support have been largely overlooked in the literature. Issues such as coping, resilience, locus of control, and social support are important components that must be investigated from patient perspectives to facilitate the development of effective and appropriate mental health and psychosocial support services. Therefore, this study aimed to explore how recovered individuals with COVID-19 have adapted to their psychological and social stressors during the infection period. Specific aims were to (a) understand the lived experience of recovered individuals with COVID-19 in terms of adapting to their psychological and social stressors during the infection period and (b) explore the sources of psychosocial support used by recovered individuals with COVID-19.

Design
A qualitative descriptive-phenomenological approach was used to explore how recovered individuals with COVID-19 adapted to their psychological and social needs. Using a descriptive phenomenological qualitative approach facilitates exploring the lived experiences of recovered individuals with COVID-19, offers a novel and innovative way to understand individual experiences, and provides evidence for proposing client-based solutions to psychological maladaptation. Data were collected using semistructured interviews.

Sample and Setting
A purposive sampling technique was used to recruit 13 recovered individuals with COVID-19. This sample was sufficient to achieve data saturation, as Glaser and Strauss (1967, p. 61) defined: "Saturation means that no additional data are being found whereby the sociologist can develop properties of the category. As he sees similar instances over and over again, the researcher becomes empirically confident that a category is saturated." The inclusion criteria included (a) over 18 years old; (b) having been diagnosed, confirmed, and recovered from COVID-19 through medical and official resources; and (c) being able to read and understand the Arabic language. No exclusion criteria were used.

Data Collection Procedure
The study was approved by the institutional review board of Al-Ahliyya Amman University (IRB No. 2S2/2019). The interviews were conducted via telephone and averaged 45 minutes in length. Data were collected and analyzed between July 2020 and March 2021. The interviews were synchronous, as they were conducted in real time, with the researchers and interviewees conversing in real time. The researchers used a network approach to recruit the participants. The researchers used social media and networking to announce the study and its purposes and significance. Those interested in participation requested to contact the research team. An electronic-version consent form was sent out and signed before conducting the interview. This consent form included the statement that the interview would be recorded for research purposes only as well as addressed issues related to confidentiality, privacy, and the wholly voluntary nature of participation. Pseudonyms were used to identify tapes and transcripts. All of the data were kept in a password-protected computer file.

Measurement
All of the data were collected in the native language of the participants (Arabic). Because a phenomenological approach was used, we used a list of interview questions to guide the interview (Table 1). In addition, an author-developed sociodemographic datasheet was used to collect demographic and disease-related information.

Data Analysis
In this study, the researchers analyzed data following Colaizzi's method of descriptive data analysis (Edward & Welch, 2011). The interviews were transcribed verbatim, and the researchers listened to each audio-taped interview multiple times. The significant statements that emphasized the phenomenon under investigation in this study were extracted from the transcripts. Next, the main themes were formulated and extracted after forming a clear and well-understood grasp of the participants' statements. The researchers organized all major themes into four main clusters based on the formulated meanings. Then, the original interview statements were compared to validate the clusters and themes. After the data analysis, two of the 13 study participants read the transcripts to confirm that the analysis accurately reflected and described their experiences. Study rigor was ensured by assessing the aspects of credibility, dependability, confirmability, and transferability. Credibility was ensured through exhausting analysis and repetitive comparison of the statements. Dependability was achieved using the code-recode procedure. Confirmability was ensured by multiple researchers performing the checking and coding procedures. Transferability was achieved by recruiting a heterogeneous sample in terms of gender, sociocultural background, and educational background.

Participant Characteristics
The age of the participants ranged from 18 to 43 years, with a mean age of 29 (SD = 8.09) years. Slightly under half of the sample (46.2%, n = 6) were male, 53.8% were single, 38.5% were educated to the high school level, and 69.2% were nonsmokers. The vast majority (n = 12, 92.3%) had no comorbidities before the pandemic and used over-the-counter drugs (n = 11, 84.6%) to treat their COVID-19 symptoms. None of the participants was diagnosed with mental illness. Most (n = 9, 69.2%) were diagnosed with COVID-19 during the second half of March 2020, and most had not been quarantined to detect infection with COVID-19 (n = 10, 76.9%). Finally, almost half (n = 7, 53.8%) had a close (first-degree) relative also diagnosed with COVID-19 ( Table 2).

Perception of Participants
Analysis of the accounts found that participants vary in their perceptions toward being diagnosed with COVID-19. The participants' perceptions depended on their subjective understanding, knowledge, and immediate illness responses. Four major themes with several subthemes were elucidated ( Table 3). The major themes included conscious awareness, uncertainty, sources of psychosocial support, and resilience.

Conscious Awareness
Conscious awareness refers to the perception that individuals confirmed with COVID-19 are provided with a bank of information (accurate and inaccurate; infodemic) and are under social, personal, and formal pressure to read, hear, exchange, and conform with information related to COVID-19. The participants in this study were not given the option to choose the sources of information but rather fed with information that formed their perceptions. The subthemes of conscious awareness identified include acceptance, victimization, and normalizing. Acceptance Acceptance reflects the recognition and awareness of confirmed infection with COVID-19. All of the participants reported accepting their diagnosis and perceived that there was no way not to accept the truth of their infection after being informed of the test results. One participant said, "I had accepted the truth of being diagnosed with coronavirus when the laboratory technician, my manager, and a member of the epidemiology committee informed me over the phone."

Victimization
Victimization reflects the societal pressure placed on people who have accepted being diagnosed with COVID-19 and being quarantined to avoid blame for being infected. The participants shared that they felt accused of spreading the infection to others and that they had been treated inhumanely by curious people who asked them questions without being useful or supportive. Moreover, these curious people tended to use the information provided inaccurately and inappropriately, causing further harm to the participants. Victimization has been reported in various forms, including bullying, labeling, breaking of confidentiality, ignorance, scrutinizing, spreading rumors, and texting, and has resulted in the participants losing control over their lives and behaviors, leading to further psychological distress and perceptions of stigmatization. One person stated, "When the media labeled me 'the xx from xx department,' those who know where I work were calling me to check, confirm, and blaming me indirectly." Normalizing Normalizing refers to the perception of some individuals confirmed with COVID-19 infection being equally and similarly treated as other diseases and that the treatment protocol is consistent. We noted that feelings related to this theme were primarily reported by those participants with relatively good knowledge about COVID-19: "I decided to take this virus like any other virus and other disease, and I got that I have nothing that I can to do!" Normalizing was also observed among those with strong religiosity and beliefs regarding destiny. Although these participants considered COVID-19 as a commonly occurring disease, they did not underestimate the disease but rather focused on reducing stress, seeking therapy and rehabilitation, and maintaining a positive outlook for the future. Rather than using scientific evidence, they depended largely on publicly known knowledge about COVID-19 and relied on spirituality and spiritual care. One participant, for example, shared: "I praise to Allah. First and foremost, this is from Allah; I trust in Allah, and whatever occurs is from Allah. Even though we were infected with the virus, we followed all safety procedures. As a result, we must believe in our destiny."

Uncertainty
Uncertainty refers to the fact that the participants received information from different resources, did not have their questions adequately answered, and, as a result, felt apprehension about their health and the health of their families. Lacking reliable sources of information, most participants felt stress from reporting on social media, which contains fake news and exaggerated content. Uncertainty includes the subthemes of apprehension and poor communication.

Apprehension
The participants expressed their fears of the disease and its effects, of contributing to the spread of the infection, and of the shortage of medical supplies in many hospitals. One participant stated: "I had a strong fear and anxiety that I might have transmitted the infection to them (means his family) even though I was taking safety precautions when I was in the house." The participants did not express their apprehension based on valid or reliable information resources, which increased their worries and negatively affected their psychological well-being. One participant emphasized these concerns: "It was really disappointing because they (healthcare professionals) were not informing us about our investigation results to know what the progress is".

Poor communication
Poor communication was observed in a number of statements from participants who expressed their dissatisfaction regarding the massive amount of information they were receiving. However, how information was given/received was described as poor. People and healthcare professionals conversed with them solely to obtain specific information rather than to listen to their perspectives or observe their progress. One participant said: "People were calling me to get information rather than to ensure that I am ok." One participant highlighted the barrier of language. She was Spanish and was thus frustrated when no one understood her. She stated: "The situation was very bad. I was suffering because no one could understand me. I was trying to understand why I was still at the hospital."

Sources of Psychosocial Support
Individuals with COVID-19 were aware of their need for psychological support from their families, friends, and healthcare professionals. However, this support was regularly inadequate in terms of adequacy, quality, type, and sources. There were three major themes: caring family, healthcare professionals' support, and self-grieving.

Caring family
This subtheme was touched on by a number of participants. Some positively described the psychological and caring aspect received from families, especially those admitted to isolation with their family members who had also tested positive. Those patients expressed having a higher sense of caring and support from their family members. One participant stated: "I think having my family members next to me even at the hospital gave me strength (laughing), I am sorry I am laughing because I am happy that they (my family) are here with me. If I were alone, I'm sure I'd be miserable." Some 2. Poor communication "People were calling me to get information rather than to ensure that I am ok." "Situation was very bad, I was suffering as no one could understand me, I was trying to understand why I am still at the hospital." Sources of psychosocial support 1. Caring family "I think having my family members next to me even at the hospital was a strength point (laughing), I am sorry I am laughing because I am happy that they (family) are here with me. If I were alone, I'm sure I'd be miserable." 2. Healthcare professionals' support "The medical staff views were great, they supported us, gave education and did all their effort to support." 3. Self-grieving "I have reviewed all the times when I visited people and all moments to find where did I get the virus and could not reach a decision or get to know." Resilience 1. Optimism "…then, after reading about the disease and infection and discovering that we still don't know much about it, I chose to isolate myself in my room and avoid contact with others for fear of re-infection." 2. Positive thinking "I had a positive feeling, I wasn't depressed, and I was able to help some of the patients who were psychologically distressed by trying to give them some of my positivity". "I am a very positive person, even in the worst conditions, I try to see in a positive way through looking a Look at the full half of the cup." "I had a positive feeling." 3. Spirituality "I am a kind of person who is not religiously committed…. I started to keep Duaa (Prayers).... In this circumstance, any person feels weak and turns to the spiritual side." Experience of Recovered Individuals With COVID-19 VOL. 31, NO. 3, June 2023 have indicated that their families were consistently knowledgeable and positive, which aided in their rapid recovery. One participant shared: "My family reassured me, saying that my health had improved and that this period would pass quickly. They used to communicate with me every day. They discussed my symptoms and were knowledgeable about them, which enhanced their awareness and gave me the idea that I was getting better." Healthcare professionals' support Informants reported positive support from healthcare professionals. Their expressions showed that this support was perceived as largely nonformal, unplanned, and not part of the treatment plan. They described this support as a form of health educational and humanistic-social support rather than therapeutic support. For example: "The medical staffs' views were great. They supported us, educated us, and did everything they could to support us." Generally, the quality of professional psychosocial support was described as poor and did not utilize specialized mental healthcare services. The participants mainly sought specialized mental health and psychosocial support, which was a general, directive, and not goal oriented. However, the participants knew their needs for specialized mental health services and referrals. One stated: "No one talked to me except for a few people, none of who were specialists. No mental health specialist contacted me. I needed to talk to managers to clarify the rumors."

Self-grieving
Although the participants expressed receiving family and professional support, they also indicated that they practiced self-grieving using multiple defense mechanisms to lower their anxiety, enable them to avoid facing the reality of their infection, and avoid thinking about the unknown consequences of the coronavirus infection. These defense mechanisms presented in various forms, with some participants persistent in the belief that they were not infected. Rather, they focused on identifying possible sources of infection and denying any connection with an infected person and the possibility that they may have been infected. One participant clearly observed an example of denial, who stated, "I have reviewed all the times when I visited people and all moments to find where I got the virus, and could not think of a single opportunity." Some participants felt shocked, sad, anxious, depressed, and self-guilt or outward-focused guilt; lost self-control; and used rationalization. Participants stated: "Once I figured out that I had coronavirus, I was shocked."; "When they told me about their infection with a virus, I felt very sad and I cried a lot."; and "I blamed myself for not taking sufficient precautions."

Resilience
Analysis of the accounts resulted in a number of expressions of resiliency as a positive reflection on their anticipated recovery and prognosis. A number of subthemes were extracted, including optimism, positive thinking, and spirituality.

Optimism
Optimism reflects a positive view on the future and perceives recovery as a matter of time, with confidence in a complete recovery and return home. Participants relied on their skills to obtain information. One person stated: "…then, after reading about the disease and infection and discovering that we still don't know much about it, I chose to isolate myself in my room and avoid contact with others for fear of reinfection." The participants also relied on received support from family and friends, which also affected their prognosis positively. One person stated: "My family, friends, and colleagues kept in touch with me in the hospital to check on my progress and even requested that I be transferred to another facility if necessary. Some members of the community also came to check on me." Moreover, some participants were asymptomatic, which gave them the power and feeling that they would recover and not be affected by the virus itself. Related participant statements included "I am a naturally optimistic person." and "I am an optimistic person."

Positive thinking
Positive thinking comes from relying more on evidence, expression, and information received from healthcare professionals. The participants who reflected positive thinking had a level of self-awareness that enabled them to look positively at their experience of being infected with a disease that people perceive as dangerous. They focused inward for evidence to offer self-comfort and assurances that the disease was not dangerous. Participants stated: "I had a positive feeling. I wasn't depressed, and I was able to help some of the patients who were psychologically distressed by trying to give them some of my positivity."; "I am a very positive person, even in the worst conditions, I try to take a positive perspective by seeing my glass as 'half full.'"; and "I had a positive feeling." Spirituality Spirituality mainly focused on the religious aspect of spiritual well-being. Their perceptions could be interpreted in a bifocal way. Participants completely believed that the disease was their fate and determined by God, believing that a supreme power controls disease and that their recovery depended on God's decision. We did not identify any passivity or negativity in thinking that would indicate a negative impact of surrendering one's fate to God. Rather, religious beliefs gave the participants strength and power to resist the disease. Some examples clearly identified "Allah," referring to God as the controller and accepting that their infection was for their own good and believed that God would help them to recover. Examples include "This is Allah's decision"; "I believe in Allah"; "I am a good believer and believe in the act of God"; and "I felt more comfortable when I went back to Allah." In addition, being infected directed people to practice spirituality and enhance their relationship with God. One participant said: "I am a kind of person who is not religiously committed…. I started to keep Duaa (Prayers).... In this circumstance, any person feels weak and turns to the spiritual side."

Discussion
In this study, the perception of being infected with COVID-19 was expressed through the four main themes of conscious awareness, uncertainty, sources of psychosocial support, and resilience. Although the participants noted sources of support through the subthemes of family caring and healthcare professionals' support, they exhibited self-grieving with various coping mechanisms. The participants also reported resilience as a major theme, which was enhanced through optimism, positive thinking, and spirituality. In this study, the spread of information about COVID-19 via the infodemic resulted in psychosocial impacts that affected their acceptance (Dubey et al., 2020). The findings of this study echo previous studies that reported that the flow of information related to COVID-19 affected the level of disease acceptance among infected people (Dubey et al., 2020;Yap et al., 2010). In this study, knowledge about the disease was found to have both positive and negative effects on the participants, which is contrary to what has been reported in other studies, which found knowledge about the disease to be correlated to positive attitudes. One explanation may relate to the high acceptance of and adherence to government guidelines and COVID-19-related information among participants in this study (Yap et al., 2010). As a novel disease, COVID-19 is associated with much stigma, and there remain many related unknowns and fears (World Health Organization, 2020). As a result of spreading incorrect information about COVID-19, participants in this study became victims of stigmatization, negative social pressure, bullying, labeling, rumors, and other negative impacts. This finding disagrees with Yap and colleagues, who found knowledge about influenza to correlate with a higher level of practice and more positive attitudes (Yap et al., 2010). Another study reported that knowledge about COVID-19 facilitated participants' willingness to accept and follow government guidelines (Roy et al., 2020). This is also partially congruent with our findings that, because of intensive exposure to the information about the pandemic, the participants increased their disease awareness by accepting the disease as a normally occurring event. Thus, the infodemic had a bifocal effect on the participants in this study that led them to adopt a positive perception of disease acceptance and a negative perception of stigmatization.
Uncertainty was identified in this study through apprehension in the participants. Community education about valid and reliable sources of information is required to reduce uncertainty. Furthermore, the participants expressed that they were poorly informed by their healthcare providers, which contributed to their uncertainty. Acknowledging patients' emotions (e.g., fear, anxiety, sadness, guilt) during the COVID-19 experience has been found to facilitate their access to critical information (Back et al., 2020). Uncertainty may also have compromised the participants' health and hindered their adherence to treatment plans and commitment to public health restrictions. Uncertainty may be reduced through open and therapeutic communications between healthcare professionals and individuals at risk or infected with COVID-19. Studies have shown that exposure to natural crises such as the COVID-19 pandemic are associated with direct (disease infection), indirect (governmental policy, action, and quarantine), and social and psychological concerns and problems, including depression, worries, anxiety, fear, nervousness, and guilty feelings, among the general population (Dong & Bouey, 2020;O'Neil et al., 2020;Roy et al., 2020). Nevertheless, a recent study showed that healthcare professionals are not knowledgeable about psychological distress related to COVID-19 and have a low level of awareness regarding their patients' mental health and psychosocial needs and priorities . This is also consistent with reports on emergency nurses' skills and knowledge regarding managing the psychological distress of patients who feel incompetent and incapacitated (AlShibi & Hamdan-Mansour, 2020). Similar to the findings of other studies, our participants were negatively affected by COVID-19 and exhibited apprehension (worries and anxiety) and a variety of emotional coping mechanisms (e.g., fear, scared, and depressed) that influenced their psychosocial adaptation and mental well-being.
Although the participants in this study expressed experiencing several negative psychological impacts, they were able to successfully adapt in healthy ways, with their COVID-19 experience reflecting a high level of resiliency. Resilience is very important to overcoming negative psychological consequences such as being infected with COVID-19 (Abu Mansour & Abu Shosha, 2022;Smith et al., 2020) and includes self-management characteristics such as positive thinking, optimism, patience, sense of humor, and spirituality (Hou et al., 2020;Soonthornchaiya, 2020). The resilience identified in this study may be related to the recruited participants not experiencing severe physical symptoms of COVID-19 and the lack of narratives from those who died because of COVID-19. We collected people's narratives after discharge, indicating recovery and physical wellness. In addition, most of the participants did not experience severe physical symptoms during hospitalization and completely recovered from COVID-19. Moreover, no patients who died because of COVID-19 were included in this study. A study conducted among Thai older adults during the COVID-19 crisis found that, besides physiological problems, religion, self-management, and emotional management were positively associated with spirituality and resilience (Arabiat et al., 2021;Soonthornchaiya, 2020). In this study, we identified positive thinking, optimism, and religiosity as major contributors to recovery from COVID-19. A previous study Experience of Recovered Individuals With COVID-19 VOL. 31, NO. 3, June 2023 also found that optimism mainly contributes to recovery and mental well-being among people experiencing posttraumatic effect (Carbone & Echols, 2017). This is echoed in this study, as the participants showed great resilience in facing their psychological problems and used positive thinking, optimism, and spirituality to relieve their stress. The results of several studies indicate that spiritual beliefs and faith significantly influence individual well-being, encourage dealing proactively with stress, and enhance hope and resilience (Meer & Mir, 2014). Therefore, professional psychosocial healthcare must be integrated into the healthcare services as a core component of treatment to achieve better healthcare outcomes.
The themes that emerged from the participant interviews are a major strength of this study. However, the study has some limitations. Although data saturation was reached, the group of 13 participants interviewed is a relatively small sample size. In addition, the sample included recovered individuals who had not experienced severe physical symptoms of COVID-19 and did not include narratives from people who died because of COVID-19.

Conclusions
Having COVID-19 infection drains individuals not only physically but also biopsychosocially. This study showed that participants exhibited multiple psychological and social problems. Although they did not receive professional mental healthcare, they overcame their problems using available social support from family, friends, and healthcare providers. They used their spirituality, optimism, and positive thinking to resist the disease and accelerate their recovery. Therefore, there is a need to organize mental health and therapeutic communication training programs for healthcare providers in general. Mental health nurses have a significant role to play in patient treatment plans, and their intervention should be integrated as a core component of the comprehensive treatment proposed for individuals with COVID-19. There is also a need to emphasize the role of liaison psychiatric nurses and mental health counselors in medical care settings. This may enable nurses to better address patients' mental health needs and priorities and assist healthcare professionals to pay more attention to mental and psychosocial care in their care plans.