Amendments from Version 1

F1000Research

2046-1402

F1000 Research Limited

London, UK

10.12688/f1000research.127578.2

Research Article

Articles

Until the dawn: everyday experiences of people living with COVID-19 during the pandemic in Thailand

[version 2; peer review: 2 not approved]

Imkome

Ek-uma

Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-5714-4249 a 1 Moonchai

Kamonchanok

Investigation Methodology Writing – Review & Editing 2 1mental health and psychiatrics nursing, Faculty of Nursing, Thammasat University, Klong-luang, Pratumtane, 12120, Thailand 2mental health and psychiatrics nursing, Srisavarindhira Thai Red Cross Institute of Nursing, Pratumwan, Bangkok, 10330, Thailand

a ek-uma@nurse.tu.ac.th

No competing interests were disclosed.

25 9 2023

2022

1560

31 8 2023

2023

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: This study aims to understand and analyze the complex experiences of people living with COVID-19 to support future cases.

Methods: Purposive and snowball sampling techniques were employed to collect data through in-depth interviews; the data were combined with non-aggregated behavioral observations. Lived experiences of 15 individuals were collected through semi-structured interviews and analyzed using a phenomenological-hermeneutic approach. We used the thematic analysis technique to analyze the data.

Results: Through analysis, themes of stress, economic impact, social stigma, social support, and unexpected benefits were identified. Participants further expressed economic and social concerns during the interviews.

Conclusion: The identified themes can help develop multidisciplinary treatment strategies that would be useful during a healthcare crisis, establish comprehensive support systems that could address economic and social problems, and provide training for employees for post-COVID-19 assistance.

COVID-19 Mental health lived experiences phenomenological-hermeneutic approach stress economic impact social stigma social support multidisciplinary treatment strategies multidisciplinary treatment teams

Faculty of nursing, Thammasat University

Thammasat University Research Unit in the innovation of Mental Health and Behavioral Healthcare

The author(s) declared that no grants were involved in supporting this work.

Revised Amendments from Version 1

This version has addressed reviewers' comments by 1) Adding the statement of the situation during the COVID-19 pandemic in Thailand. 2) The gap of knowledge was a citation 3) Adding an explanation of how the interview questions were developed. 4) rephrased the statement to make it more transparent on the part of the procedure 5) Added the state of the Ethics Review Committee’s institution 6) Trustworthiness was describing 7) The IPA was added as an analysis method. 8) Table 1 - The marital status "Couple" means living with a partner and/or married

Introduction

Over 219 million cases of COVID-19 were reported globally until October 10, 2021. With 4.55 million fatalities and threats of new variants, the virus continues to evolve. To control COVID-19 outbreaks, governments and health experts worldwide have been experimenting with various vaccines, treatment modalities, new measures, and preventative strategies within a short timeframe. Lockdowns and lenient curbs have caused turmoil worldwide since the beginning of the pandemic. People have been trying to use several new coping strategies to deal with market turbulence ( Nurunnabi et al., 2020). After its rapid spread worldwide, the number of people contracting COVID-19 and succumbing to it reached 512,963,517 and 6,259,611, respectively, by May 25, 2020 (World Meter, https://www.worldometers.info/coronavirus/). COVID-19 outbreaks affect the population’s immediate morbidity and mortality from COVID-19, disrupt the emergency care for non-COVID-19 conditions, change chronic illness care modality, and rapidly escalate the incidence of mental health problems such as stress, depression, and anxiety ( Sing, et al., 2021). Approximately 20% of all COVID-19 cases may experience severe symptoms, and require oxygen therapy or other inpatient interventions, and only 5% require hospitalization in the intensive care unit ( Wu & McGoogan, 2020). However, studies have reported that COVID-19 has a broader physical and psychosocial impact beyond acute symptoms. Patients with COVID-19 demonstrate various symptoms such as fever, dyspnea, muscle ache, headache, fear, diarrhea, nausea, vomiting, increased systolic blood pressure, and hemoptysis, all of which require invasive and non-invasive therapeutic support during the acute course of the disease ( Davis et al., 2019; Huang et al., 2020). The mortality rate of COVID-19 has been estimated to range from 1% to 5%, but this varies depending on patients’ age group and the presence or absence of underlying diseases. The epidemiological distribution of mental health problems and associated factors are heterogeneous among COVID-19 patients. The current evidence suggests that a psychiatric epidemic is co-occurring with the COVID-19 pandemic, which necessitates the attention of the global health community ( Hossain, 2020). During the COVID-19 pandemic in Thailand, patients have faced problems such as fear, loneliness, boredom, anger, anxiety, insomnia, and a feeling of taboo. Patients have also been concerned about the effect of being quarantined on their psychological well-being and the risk of infecting family members and community members. In Thailand, from 3 January 2020 to 30 August 2023, there have been 4,756,406 confirmed cases of COVID-19 with 34,459 deaths, a total of 139,279,946 vaccine doses have been administered ( WHO, 2023).

Researchers primarily conducted epidemiological studies and clinical trials during the initial crisis response to the pandemic. However, qualitative research is needed to provide the nuance and detail of COVID-19 patients’ lived reality and contextualized experiences due to the knowledge, understanding, advanced nursing intervention, medication, alternative treatment, and psychosocial intervention were lacking. Such rich data can help develop interventions and policies alongside obtaining quantitative data ( Tremblay et al., 2021). Besides, a few studies have explored the needs of COVID-19 cases, their stress and adaptation to the disease, economically, quality of life, and health support ( Setiawan, Wardani, & Theresia, 2023). Explaining the perspectives of people living with COVID-19 on their needs and the impact can help improve the quality of care and their quality of life. The study findings can guide policymakers in making public policy decisions and strategic plans for public health organizations, and provide accessibility of assessment and treatment services, thereby improving the quality of care provided to this population and ensuring research subsidy priorities at state, regional, and national levels. Additionally, the findings can guide public mental health initiatives across multiple ecological levels that can mitigate the toll of COVID-19.

Theoretical perspective

The theoretical framework of this study will help deepen our understanding of the lived experiences and the impact of COVID-19 on patients. The Roy adaptation model ( Roy, 2001, 2009, 2011) states that the three elements are coping processes, adaptive modes, and adaptive levels. Coping processes are primary elements of understanding individual COVID-19 cases, their adaptation, and their life strategies for enhancing adaptation. Furthermore, the adaptive modes classify COVID-19 case data and help us understand this population’s daily life and experiences of people living with COVID-19.

Methods Design

This research applies narrative-based data collection procedures (NbDC). NbDC ( Kirkpatrick, 2008), underpinning the phenomenological-hermeneutic approach, allows researchers to listen to and understand human experiences and contribute to planning quality of care in the future.

Participants

Fifteen participants were selected through purposeful sampling. As per the inclusion criteria, participants included COVID-19 survivors who had been discharged from the hospital and provided written consent for participation. COVID-19 cases that experienced stress or mental health problems were prevented from giving informed consent, and their participation was thus excluded.

Procedures

The phenomenological-hermeneutic approach was applied to examining and interpreting lived experiences and perceptions related to the COVID-19 pandemic ( Al Kalaldeh et al., 2018; Graor & Knapik, 2013; Kvale & Brinkmann, 2014). Dialogical conversations were conducted with participants who were in a vulnerable state. During the interviews, the interviewer used a checklist to report essential aspects of the research team, methods, context, findings, analysis, and interpretations ( Tong et al., 2007).

Data collection

We recruited participants through the nursing offices of a hospital in a different location in Thailand. First, participants’ willingness to participate was sought through phone calls. Second, the nurse apprised the participants of the interview. Third, semi-structured individual in-depth questions were developed by reviewing the literature on the concept of stressful life events, adaptation and emotions. The three validators checked the content and comments. The video interviews were conducted via Microsoft Teams in a time slot of the participants’ preference after explaining the research goals and acquiring their verbal and written consent. The sampling process continued until data saturation and the saturation were reached when no additional data were found, and the researcher, a psychiatric nurse, took on the role of interviewer to maintain a professional relationship with the participants. The duration of the interviews was between 25 and 60 minutes. Data were anonymized. In the final step, the transcripts were returned to participants for comment and/or correction.

Ethical approval

Ethical approval was obtained from the Human Research Ethics Committee of Thammasat University (Science), (COA No. 119/2563) on 20 October 2020.

Consent

The research scope, risks, and benefits were explained to the participants; they were assured that anonymity and confidentiality would be maintained. They were informed that their participation in the research was voluntary ( Imkome & Moonchai, 2022). We confirm that we obtained written and verbal consent to use data from the participants included in this study. The interview duration was determined based on the participants’ preferences, patience, and experiences. All interviews were recorded on video via Microsoft Teams of Thammasat University as a host and confidentially. The system automatically deletes data after recording for a month. The record was kept for a year for data checking and reference. Then, the computer of the researcher deleted the data and format.

Data analysis

Interviews and data analysis were conducted simultaneously using the phenomenological-hermeneutic method ( Kvale & Brinkmann, 2014). A good rapport, member check, peer debriefing, and researcher triangulation reflect the trustworthiness of this study. The researcher analyzed the transcripts independently using an IPA framework ( Smith & Osborn, 2015; Alase, 2017). The three levels of description and interpretation were processed. The first level was self-understanding, wherein in the first readings, the authors created the narrative, summarized all the participants’ experiences, and protected data anonymity. The second level was structural understanding, as several readings of the transcription constructed general themes, and we named and interpreted the central theme. We analyzed the data using SPSS Modeler software ( RRID:SCR_002865) for qualitative data analysis. The third level was a theoretical interpretation that was extended through theoretical interpretation. The Roy adaptation model ( Roy, 2011) was applied.

Results

This section describes the participants’ understanding through a structural account of the findings, followed by a theoretical interpretation of the results.

Level 1: Participants’ demographic data and their self-understanding

Out of the 15 participants, 11.33% were unemployed, and 62.5% had an insufficient family income per month ( Table 1). The data analysis led to four themes ( Figure 1).

Table 1. Demographic COVID-19 cases of informants (N=15).

Demographic data		N (15)	%
Age
	1. < 30 years	2	13.33
	2. 31–40 years	8	53.34
	3. 41–50 years	2	13.33
	4. 51–60 years	1	6.67
	5. > 60 years	2	13.33
Gender
	1. Female	6	40
	2. Male	9	60
Marital status
	1. Single	5	33.34
	2. Couple (living with a partner and/or married)	4	26.66
	3. Widow	2	13.33
	4. Divorced/Separated	4	26.67
Level of Education
	1. Primary school	1	6.67
	2. Secondary education	3	20
	3. Vocational Certificate/Higher Vocational Certificate/ Diploma	7	46.67
	4. Bachelor's degree or higher	4	26.66
Career
	1. Government service/state enterprise employee	4	26.67
	2. Trading or running a personal business	2	11.33
	3. Company employees	3	20
	4. Hire	4	26.67
	5. Unemployed	2	11.33
The family income per month (estimated)
	1. Fair	4	25
	2. Not enough	10	62.5

Figure 1. Themes of the study (Apply from <xref ref-type="bibr" rid="ref28">Roy (2011)</xref>). Level 2: Structural understanding

These early findings highlight how the comprehensive theme shaped by the participants’ of experiences and the impact of COVID-19. Major themes derived from content analysis were evident across interviews and included stress, economic and social impact, social stigma, and the concept that bad luck occasionally brings good luck, which was described in all interviews. Positive experiences of “feeling good” and “social support” were also emphasized throughout the transcripts ( Figure 1).

Stress

In this context, stress refers to how people with COVID-19 perceive the infection and related circumstances as threatening and challenging to manage.

“It is stressful to be alone in the room. It was not easy to go out and find food. The city was locked down; what would happen next? Will our family be okay? Will the people who live in the community hate us? A disease spreading heavily in Thailand is stressful.” (Cl. 1)

“Going to the hospital, I coughed a lot the first day and felt stressed, and I did not feel better on the third day. The doctor from the hospital called to check my signs and symptoms, and I felt like I would not survive. After being admitted to the hospital, I was completely unconscious for about 40 days. What is the difference in oxygen? What is bulking? My family cannot visit, but they can look from outside.” (Cl. 9)

“Covid infection affects health and causes stress.” (Cl. 15)

Economic and social impact

The economic and social impact here refers to the physical, mental, social, spiritual, and economic situations that people living with COVID-19 experience that affect their daily lives.

“After being infected with COVID-19 and locked down, I had no job. When there was no job, there was no money. I kept saving money until I could not manage it. Shops were closed, so it was not easy to buy food. My salary was reduced when I returned to work because we were expected to help the company financially. Our expenditures remained the same, but our incomes were smaller, which had a huge impact. But other matters are not affected as much as the finances.” (Cl. 1)

“An essential part of people today is the economy. If the economy is good, mental health is good. I do not need anything; trade does nothing; I do not feel upset and offended; I am already happy. It is a good environment; it is good, I think. Everyone has their duties. Why are there so many robbers and thieves? Maybe because they do not have a choice. The whole problem lies in economic and mental health.” (Cl. 3)

“A stupid economy. If we get infected, we cannot work; it affects our family.” (Cl. 5)

“In health, stress, or unemployment, I have no money to spend like this.” (Cl. 6)

“COVID-19 is affecting work. I closed shop; cannot open now; no money.” (Cl. 13)

“I am unemployed, and I have no money.” (Cl. 15)

Social stigma

In this study, social stigma refers to how people with COVID-19 are stereotyped and treated with discrimination, dissociation, and loss of certain status due to association with a perceived disease.

“It is stressful that people around you have to be poorly judged by society, such as when someone was evicted from their condo when it was learned that he had infected a friend with COVID-19 even though he had a young child. Some people know that it is my friend in the condo. So many people push them away from their homes. I told him to go elsewhere for 14 days and then return.” (Cl. 5)

“An infected friend posted a picture on Facebook. There will be a team to hunt him. This is a true story.” (Cl. 5)

“Do you not understand? Are you disgusted or not? My mother told a group friend that her daughter was infected with the coronavirus. My mother gave them a gift and souvenir, and they returned it as if afraid it was infected with COVID-19.” (Cl. 8)

“I had to stop work. I had to take a break from work first. It was too bad. My friend is a football coach, and he has COVID-19. Parents do not let their children learn football from him. The room was locked when he returned to his condo; the owner had kicked him out.” (Cl. 11)

“You will be stigmatized by society as an infected person. You have to go somewhere else. Those who are infected or have a friend who is infected are disrespected and bullied. Let us go together and not live in a normal society.” (Cl. 13).

Social support

In various fields, social support involves purposeful interactions that bring about help. For those infected with COVID-19, cultivating concrete and abstract assistance, such as recognizing, understanding, and responding to emotions, providing information, giving objects, and being accepted as part of the group, affects how a person perceives social support. Individuals are perceived as being loved, cared for, valued, and positively affected by their physical and mental health. This enables a person to face life-threatening events more effectively.

“I call home every day, and I jog to my room to watch television.” (Cl. 2)

“During stressful times, listening to music, reciting the prayers, doing housework, and watching TV with my girlfriend can relieve stress.” (Cl. 4)

“I was infected, and therefore [my] friends were exposed. They only have sympathy for us. We called to apologize. He said hey, it is okay. You can take care of yourself. It is not a problem. He wanted to encourage us and not make us more stressed.” (Cl. 5)

“I have a neighbor who acts as if she is his older sister and consults about dealing with COVID-19.” (Cl. 6)

“Luckily, most people are encouraging, and those around sick people are worried. They will never bully or scold.” (Cl. 1)

“When stressed, I listen to music and watch TV.” (Cl. 4)

“Doctor and his teams were highly qualified, and people received good treatment; they felt confident, and their health status gradually improved.” (Cl. 1)

“The health team from the hospital that has taken care of me since I was discharged still contacts me to ask about my symptoms, invite me to work, become a lecturer, and sometimes get a job. Recently, the agency made an appointment for an interview. If anything could help, such as providing information about COVID-19 or others, I would be happy to help. The hospital produces an application called Clinical App to track the symptoms of COVID-19 patients. So we do not have to go to the hospital. You can ask for advice in the app. There will be a team that takes care of coordinating.” (Cl. 1)

“Bang Khae Health Center contacted and coordinated care such as home visits and consults. They gave good help.” (Cl. 2)

“During the treatment, the medical team was excellent and did not show disgust. The doctors and nurses took good care of the patients, spoke well, cared for them, and encouraged them. They gave us medicines, checked the temperature and pressure, and always called to tell us. They provided detailed treatment care. The medical team is perfect.” (Cl. 4)

“At that time, I was in an intensive care unit. The healthcare team provided a PPE gown. All the care and treatment procedure was done quickly so that I could get out of the intensive care unit faster.” (Cl. 5)

“I was very well taken care of. The doctor would video call and ask about my condition. Then, a doctor would check the fever in the morning and evening. Everything about the food was good. I got lung x-rays, and they took blood samples. When I came out of the hospital, I called to ask, but I did not come to visit because it was difficult. After all, I was staying at work—I called to ask.” (Cl. 6)

“When my symptoms improved and I woke up in the hospital, the doctor took good care and was friendly.” (Cl. 9)

“The healthcare team at the Tambon health-promoting hospital providing care is outstanding, so I call and ask about health issues when I get any problem. They support me when I get a problem by providing information and medicine.” (Cl. 10)

“During the hospital stay, we would talk on the phone. He would call to check the fever, check here and there, and check every time there was a headache and fever. Ask how we were feeling. Check in the morning and at noon. If we had a fever, we called via Line and told him. There was a blood test and heart rate measurement. Since I coughed a lot, I had many medicines but no side effects. As soon as it got into my lungs, I suffered for 4–5 days, but now my lungs are normal, and I only had medication.” (Cl. 14)

“I wish there were a cure for the disease. It is essential for life because it is not only in Thailand; it is worldwide, and I want it to be researched quickly.” (Cl. 11)

“At first, I was worried because it was a new case. I do not know what the symptoms of COVID-19 are. Believing in the craftsmanship of Thai doctors and their teams, I felt that it was not scary, and I was fortunate to be taken care of by a hospital that felt that it was a leading hospital, so I was not worried.” (Cl. 1)

Sometimes, bad luck brings good luck

Good luck in unfortunate situations means someone with COVID-19 has symptoms and needs to be treated in a hospital. There are various consequences, but one can get through that period.

“It was good luck in bad luck. Our bad luck is being infected with COVID-19, but good luck is learning things that we did not know before, such as knowledge of the disease and, most importantly, society. Encouragement and being a spokesperson. We felt lucky because we could not find an experience like this. Advertising for life insurance companies and interviews with other agencies, including this interview and conducted research, is something that other people cannot do because they have not been infected. I am fortunate in the misfortunes that I have to face in this life.” (Cl. 1)

“When I found out that I was infected, I felt unlucky. There was a feeling of ’why so unlucky.’ But I was lucky enough to enter the treatment process until finally recovering and going out to live a normal life. I think that COVID-19 also brings good things, such as getting to know the medical system in Thailand. There is a line between the patient group and doctors in the medical personnel and equipment system. I will ask a lot because I want to know and check it out on Facebook. We will ask and check with the doctor. After getting the information, try to share it on Facebook with some friends. This infection was helpful. It is not just a punishment. It allows us to spread good things and benefit others after we are infected with COVID-19. We are lucky to be able to benefit society.” (Cl. 5)

Level 3: Theoretical interpretation

Adaptation is a concept that has been used to realize participants’ experiences, and further illumination can be gained through the Roy adaptation model ( Roy, 2001, 2009) . Based on this model, the participants’ stress, economic and social impact, social stigma, social support, and a sense that sometimes bad luck brings good luck can be interpreted.

This model is based on the four dimensions as the person submitted to a scheme, including the stimulus, which generates the coping mechanisms and results that make up the individual, family, and community response. This scheme focuses on three stimulus types: 1) focal stimuli, which require stimulation, including fatigue, dyspnea, high fever, and cough, i.e., the signs and symptoms of COVID-19; 2) contextual stimuli, which can be defined as comorbidities; and 3) residual stimuli, which are described as internal and external factors, such as stress from unemployment, viral infodemic, financial problems, social stigma, and lack of appropriate Personal Protective Equipment (PPE).

Adaptative behavior is assessed in four modes: physiological, self-concept, role function, and interdependence. Additionally, the subdivided models are regulators, including the physiological mode, which we describe as the situation and function of people infected by COVID-19. This is pertinent since the body’s homeostasis is directly related to the lower probability of worsening symptoms. Secondly, the cognate coping mechanisms are self-concept, role function, and interdependence. The self-concept mode defines coping and highlights psychological and spiritual aspects. Indeed, considering the context of stress generated by this pandemic, asking for emotional support in chaotic times eases anguish and favors psychological well-being. The coping mechanism that complements the role function mode refers to the individual’s ability to understand their role in the world and the self-knowledge of their role in society. During the pandemic, this acknowledgment is necessary because the population does not participate in essential services; instead, it supports control measures when it fulfills social isolation measures such as visiting the hospital after an appointment.

In contrast, in the scope of essential services, health professionals, for example, legitimize their functional importance when they perform their duty with technical skills and humanity. The coping mechanism of the interdependence mode includes the affective demands of everyone. In fact, with a social distancing policy, it is common to observe anguish in the community, which has a particular need related to complete well-being. However, information and communication technologies can be alternatives to increasing physical distancing and its repercussions on the population’s biopsychosocial health. For the interdependence mode, social support from family and multidisciplinary treatment teams can decrease the experience of fear around the transmission and conditions related to COVID-19. Social stigma increases the participants’ stress, which increases the severity of COVID-19 (Sing et al., 2021).

In conclusion, the theoretical interpretation of COVID-19 case perceptions showed that participants experienced stress, economic and social impact, stigma, and social support during the global COVID-19 pandemic. The participants’ adaptive process promoted their mental integrity and positively affected their health. Nonetheless, they discussed their existential perceptions during the interviews, raising questions about work and the future during crises. Knowledge gathered from this point of view will help plan to fight such crises in the future.

Discussion

An interest driving this study was to 1) describe the stressful experiences of life during the COVID-19 pandemic and 2) describe the impact caused by the COVID-19 infection on those infected during the global COVID-19 pandemic.

Stressful experiences in life caused by the COVID-19 pandemic

People with COVID-19 were stressed by being in lockdown and quarantined. Difficulty finding food sources and disgust from the community exacerbated the symptoms of the disease.

Social stigma toward people with COVID-19 existed among people such as relatives or neighbors who feared infection. People with COVID-19 were severely judged by society and experienced situations such as being hunted by a group of citizens who came to find them, who then publicized infection information, meaning that there was no safe place in society. The owners locked rooms and stopped renting to patients. Patients were kicked out of their place ( Tsai & Wilson, 2020) and were insulted and bullied. Anyone who had an infected friend was stigmatized by society, meaning they could not stay together and not live in a typical community. Shreyaswi & Shashwath (2020) reported that reducing stigma and providing mental health services is a necessary public health response to COVID-19. Challenges related to the spread of COVID-19, stigma, and discrimination can affect patients diagnosed with COVID-19 and those who are quarantined. Effective communication is both accurate and timely. It positively affects coordination and community involvement and is a cornerstone for reducing stigma and promoting mental health. Besides, an integrated psychosocial rehabilitation program to reduce social stigma and improve the resilience of COVID-19 patients is needed ( Son et al., 2021). While several steps are required to address stigma and promote mental health, a clear strategy to integrate mental health services into meeting public healthcare needs becomes necessary during the pandemic; for example, elaborating on possibilities to deliver mental health care through technology.

Additionally, participants mentioned the impact of stigmatization and discriminatory experiences on physical and psychological health during the pandemic. This situation has increased discrimination against East and Southeast Asians, with reports of anti-Asian harassment and attacks rising globally ( Lee & Waters, 2021; Chen et al., 2020; Dhanani & Franz, 2020; Hahm et al., 2021; Noel, 2020).

Among those infected with COVID-19, social support was received during the COVID-19 outbreak, including treatment and assistance, information, and material provisions. For example, the landlord and neighbors showed no disgust when accepted as a part of society. Receiving love, care, appreciation, and acceptance from friends and family, such as encouraging calls during treatment, friends that did not mind doing activities with family members, such as exercising, listening to music, or watching TV, and consulting trusted people, such as a family member, and a health team that provided good care was also experienced. Hospitals produced an app called Clinical App to track the symptoms of COVID-19 patients, coordinate care, ask questions, help people receive care at home, and give advice; on this app, the medical team was beneficial and did not show disgust. Nurses took good care of the patient, unconditioned positive regards of care, encouraged ( Galehdar et al., 2020a), ( Galehdar et al., 2020b) and made video calls to ask about patients’ symptoms. Nurses checked their temperature in the morning and evening. Lung X-rays were obtained. A study by Rathnayake et al. (2021) examined nurses’ perspectives on caring for COVID-19 patients; their phenomenological study found that nurses were willing to provide care for COVID-19 patients because it was their duty and responsibility as well as a humanitarian issue. In the beginning, infected people always thought they were unlucky because of the infection’s severe economic, social, health, and mental impacts. However, after entering a good treatment regimen, symptoms improved, and they found themselves fortunate to be cured of this disease. Many established friendships with the health team. They acquired good morale and the ability to educate and share experiences during treatment to benefit society.

Impact of the COVID-19 pandemic

People were unhappy during the COVID-19 lockdown. The physical, mental, social, spiritual, and economic impacts experienced by people with COVID-19 affected their daily lives, such as having no job and using their savings instead of their salary. Unbalanced trade led to more robbers and thieves and increased stress and depression ( Joo et al., 2021). this is consistent with a study by Hertz-Palmor et al. (2021) that examined the relationship between income loss, financial strain, and depressive symptoms during COVID-19. Moreover, according to research by Lei et al. (2020), stress during COVID-19 impacted the participants, and individuals with no psychosocial support were highly vulnerable to anxiety and depression during this pandemic ( Hossain et al, 2020). Moreover, Nicola and research teams ( Nicola et al., 2020a) ( Nicola et al., 2020b) reported that social support was associated with a lower risk of mental health problems and correlated with another study of emotion regulation growth during the pandemic ( Cuan-Baltazar et al. 2020; Dhanani, & Franz, 2020). Post-traumatic growth, psychological conditions, and both hopeless and post-stress growth were reported during the COVID-19 pandemic ( Qi & Sheng, 2022; Gutiérrez-Cobo et al., 2021; Hu et al., 2021).

Limitations

The interview was conducted during community quarantine and after the participant was discharged from the hospital. The participants may have had stress and anxiety about their health status, long COVID, work, and economic problems; this may have prevented the authors from fully understanding the studied phenomena. In addition, the research consisted of a homogenous population of only 15 participants. Thus, a similar study that included these participants might have revealed different perceptions of experiences. The small sample size also increased the risk of bias.

Conclusions

This research explores the impact of COVID-19 on patients by analyzing their lived experiences. The data show that COVID-19 patients were psychologically, physically, socially, economically, and spiritually affected by the disease. Therefore, healthcare staff and other support systems should be comprehensively maintained by offering economical, employee-oriented, or occupational therapy and establishing a new career that includes providing training for post-COVID-19 treatment.

Implications for nursing and health

Policy implications •

The research shows that stress, economic and social aspects, social stigma, social support, and the concept that sometimes bad luck brings good luck have impacted COVID-19 cases. We recommend that the government provide a policy to support the incomes, employment, and training of this new era’s career in the new generation.

•

Understanding the challenges that the COVID-19 cases faced in these outbreaks (stress, economic and social aspects, social stigma, social support, and the concept that sometimes bad luck brings good luck) will advance hospitals and nurses to prepare better for the future.

Nursing interventions •

Social stigma is the factor that influences COVID-19 cases to worsen and leads to mental health problems. Media can efficiently decrease social stigma in the community via social media and gain more cooperation from the healthcare unit in the community.

Nursing research •

There is a need for a more exhaustive holistic assessment, including return-to-work strategies for future research studies.

•

This research depicts the impact of stigmatization and discriminatory experiences. This increase in discrimination and harassment has important implications for health care/nursing care.

•

Considering the limitations of this study, other researchers should use larger sample sizes or conduct research in other regions of the country.

Ethical approval

Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Participants (COA No. 119/2563) on 20 October 2020.

Consent

The authors obtained written and verbal informed consent from all participants to use their data in this study.

ORCID IDs

Ek-Uma Imkome https://orcid.org/0000-0001-5714-4249

Data availability Underlying data

Figshare: Until the Dawn: The Impact of COVID-19, https://doi.org/10.6084/m9.figshare.21369810 ( Imkome E-u, & Moonchai K, 2022).

The project contains the following underlying data: •

Demographic questions

•

Field notes

•

Participant information

•

Semi-structured interview questions

•

Raw data

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

This research was supported by Thammasat University Research Unit in the innovation of Mental Health and Behavioral Healthcare and funded by the Faculty of Nursing, Thammasat University.

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Reviewer response for version 2

Kin

Cheah Phaik

1 Referee https://orcid.org/0000-0002-2615-5217 1Faculty of Arts and Social Science, Universiti Tunku Abdul Rahman, Petaling Jaya, Selangor, Malaysia

Competing interests: No competing interests were disclosed.

3 10 2023

2023

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

reject

Because this study was done in Thailand, it is helpful to describe the situation there during the pandemic to help readers understand the context in which this study was based.

COMMENTS: “During the COVID-19 pandemic in Thailand, patients have faced problems such as fear, loneliness, boredom, anger, anxiety, insomnia, and a feeling of taboo. Patients have also been concerned about the effect of being quarantined on their psychological well-being and the risk of infecting family members and community members.”

This statement was added by the authors to provide contextual and background information. However, no reference was provided. As the study is based in Thailand, the authors must explain the context with conviction and support. Given the many papers published about the Covid (and lockdown) situation and issues faced in Thailand, many references are available.

The knowledge gap needs to be further established and supported to justify the need for this investigation and the significance of this study.

It is important that the researchers provide support for this statement - "Besides, a few studies have explored the needs of COVID-19 cases, their stress and adaptation to the disease, and health support."

In this regard, it would also be appropriate to refer to past studies that have been done in Thailand, as well as in other countries to establish the need to conduct this investigation and fill this knowledge gap.

COMMENTS: “Researchers primarily conducted epidemiological studies and clinical trials during the initial crisis response to the pandemic. However, qualitative research is needed to provide the nuance and detail of COVID-19 patients’ lived reality and contextualized experiences due to the knowledge, understanding, advanced nursing intervention, medication, alternative treatment, and psychosocial intervention were lacking.”

The authors described the gap. Proof or support is needed to establish this gap. There are existing studies that have reported on the experiences/perspectives/ impact of Covid among survivors. There are also studies have reported the impacts, perspectives and experiences on other specific segments e.g. nurses, students, patients, people with a certain type of disease (e.g. HIV/AIDS, diabetes) while other studies have reported on broader or more general segments.

Therefore, it is not clear how this study contributes to existing knowledge. The authors need to describe and establish this gap, justifying the need for this study, and thereby explaining the new or novel ideas that this study provides.

Theoretical framework - While it is helpful to use a theoretical framework to guide this work, the researchers need to explain how this model is not stifling this study that uses qualitative methods, ensuring that it does not limit creativity or the exploration of alternative perspectives, but rather enhances understanding and provides a structured approach to the research.

COMMENTS: There was no response from the authors on this feedback.

Methods

In the same vein (ie. No. 3), please explain how the interview questions were developed.

The authors have added the statement above. As I have commented earlier, “In the same vein (ie. No. 3)” as the authors had used a theoretical framework (as mentioned in No. 3 above), but it is not clear how or where. Was “concept of stressful life events, adaptation and emotions” adapted from the Roy Adaptation Model? If yes, I think some critique and justification are also needed for No. 3 above.

Also, this also needs to be explained further how this model was adopted in this study, while using the IPA approach.

This statement can be rephrased to make it clearer. Does it also mean that the authors have designed the interview questions by drawing upon the instrument/findings from these studies? - "The phenomenological-hermeneutic approach was applied through discussions after examining and interpreting lived experiences and perceptions related to the COVID-19 pandemic ( Al Kalaldeh et al., 2018; Graor & Knapik, 2013; Kvale & Brinkmann, 2014)."

COMMENTS: The instrument needs to be described. If the questions cannot be shared or published, then a more detailed description of what questions were asked would help.

"Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Participants (COA No. 119/2563)" - Please state more specifically which committee this refers to e.g. the University of ??? Ethics Review Committee for Research Involving Human Research Participants

COMMENTS: Noted with thanks.

Please state when these interviews were carried out as this is a cross-sectional study.

COMMENTS: No response was given to this suggestion.

Please describe how the authors ensured data trustworthiness

COMMENTS: The authors mentioned “Trustworthiness was describing”

in their response to the suggestion. It is not explained how, for example, criteria such as credibility, transferability, dependability or confirmability are ensured. However, the author did mention that “A good rapport, member check, peer debriefing, and researcher triangulation reflect the trustworthiness of this study. The researcher analyzed the transcripts independently using an IPA framework ( Smith & Osborn, 2015; Alase, 2017).” Authors could explain these procedures in relation to one or more of the data trustworthiness criteria. It is also helpful to explain how each was carried out i.e. “a good rapport, member check, peer debriefing and researcher triangulation.”

Please provide support and justification for the data analysis methods employed.

COMMENTS: As procedures were using the IPA framework, how was the Roy Adaptation Model

Results

Table 1 - The marital status "Couple" means living with a partner or married?

COMMENTS: “ Table 1 - The marital status "Couple" means living with a partner and/or married.

Noted with thanks. This makes it clearer.

Level 1 - It would be helpful to describe the results found about the respondents Self-Understanding.

COMMENTS: No response provided. No explanation is found in the paper.

Is Figure 1 showing the results of this study? What does this statement mean - "Apply from Roy, 2011"? There may be a typo or grammatical mistake here.

COMMENTS: No response provided

It is not clear why the Results of the analysis are labelled as "Level". This is not a conventional way to report the results of a qualitative study. Labelling each theme/category as a "level" indicates a hierarchy. Is this the intention, if so, the hierarchy is not clear.

COMMENTS: No response provided.

The sub-themes in Leval 2 appears confusing. From the formatting of the paper, it appears that within "Level 2: Structural understanding", there are Stress; Economic and Social Impact; Social Stigma; Social Support; Sometimes, bad luck brings good luck. Are these sub-themes all of the same level sub-themes under "Level 2"? Or are some of them of a third level sub-theme?

COMMENTS: No response provided.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Imkome

Ek-uma

Competing interests: I declare that the authors have no competing interests as defined by F1000Research, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

16 1 2024

We appreciate your thorough evaluation of our work, strengthening our quality and clarity. We have carefully reviewed the comments. As suggested, we would like to provide a point-by-point response. We are confident that with your support, our manuscript will meet the high standards of F1000Research. If you have any more suggestions, please do not hesitate to contact us. We are eager to work collaboratively to ensure the success of our manuscript.

1. Because this study was done in Thailand, it is helpful to describe the situation there during the pandemic to help readers understand the context in which this study was based.COMMENTS: “During the COVID-19 pandemic in Thailand, patients have faced problems such as fear, loneliness, boredom, anger, anxiety, insomnia, and a feeling of taboo. Patients have also been concerned about the effect of being quarantined on their psychological well-being and the risk of infecting family members and community members.”

Author response: Thank you very much. We added information and the references were addressed as the list below:

“During the COVID-19 pandemic in Thailand, people have faced problems such as stress, fear, loneliness, boredom, anger, anxiety, insomnia, a feeling of taboo, and low health literacy (Suwanaphant et al., 2020; Choompunuch et al., 2021; Boondiskulchok et al., 2022; Suanrueang et al., 2022; Taweewun et al., 2022). Moreover, people have also been concerned about the effect of being quarantined on their psychological well-being, acute health conditions, the risk of infecting family members and community members, and the sorrows and worries that influence jobs and income (Yongthasaneekul & Thammaboosadee, 2021; Wongtanasarasin, Srisawang, Yothiya, & Phinyo, 2021; Hall, Sanchez, Da, Bennett, Powers, & Warren, 2022)”.

References

1. Taweewun Srisookkum, Somkid Juwa, Orathai Katkhaw, Tienthong Takaew, Saengduean

Phromkaewngam, Naphat Prapasuchat. Health literacy, anxiety and stress among people during Coronavirus-2019 pandemic at the northern of Thailand. J Public Hlth Dev. 2022;20(3):221-235 (https://doi.org/10.55131/jphd/2022/200318)

2. Suanrueang P, Suen MW, Lin HF, Er TK, Michaela M, Jamora Q. The impact of the covid-19 pandemic on anxiety, health literacy, and eHealth literacy in 2020 related to healthcare

behavior in Thailand. J Public Hlth Dev. 2022;20(1):188-202. doi:10.55131/jphd/ 2022/

200115.

3. Boondiskulchok S, Weerametachai S, Leesri T. Prevalence and associated factors of stress and depression among SARS-Cov-2 patient in field hospital, Saraburi hospital. Regional Health Promotion Center 9 Journal. 2022; 16(2).

4. Choompunuch B, Suksatan W, Sonsroem J, Kutawan S, In-udom A. Stress, adversity quotient, and health behaviors of undergraduate students in a Thai university during COVID-19 outbreak. Belitung Nursing Journal. 2021;7(1):1-7. doi: https://doi.org/10.33546/bnj.1276

5. Suwanaphant K, Seedaket S, Vonok L, Assana S, Wawngam W, Kingsawad K, On-Kail P. Factors associated with stress due to corona virus disease 2019 (COVID-19) pandemic among students of the Faculty of Public Health and Allied Health Sciences, Praboromarajchanok Institute. Journal of Health Science Research. 2020; 14(2):138-4.

6. Wongtanasarasin, W., Srisawang, T., Yothiya, W., & Phinyo, P. (2021). Impact of national lockdown towards emergency department visits and admission rates during the COVID-19 pandemic in Thailand: A hospital-based study. EMA - Emergency Medicine Australasia, 33(2), 316-323–323. https://doi.org/10.1111/1742-6723.13666

7. Yongthasaneekul, T., & Thammaboosadee, S. (2021). Emotion and Worry Measurement Comparison of United Kingdom and Thailand During The First COVID-19 Lockdown Situation. 2021 IEEE International Conference on Bioinformatics and Biomedicine (BIBM), Bioinformatics and Biomedicine (BIBM), 2021 IEEE International Conference On, 2924–2930. https://doi.org/10.1109/BIBM52615.2021.9669723

8. Hall LR, Sanchez K, Da Graca B, Bennett MM, Powers M, Warren AM. Income Differences and COVID-19: Impact on Daily Life and Mental Health. Popul Health Manag. 2022 Jun 1; 25(3):384–91. https://doi.org/10.1089/pop.2021.0214 PMID: 34652228

2. The knowledge gap needs to be further established and supported to justify the need for this investigation and the significance of this study.

It is important that the researchers provide support for this statement

- “Besides, a few studies have explored the needs of COVID-19 cases, their stress and adaptation to the disease, and health support.”

Author response: Thank you for pointing out the important issue. According to your comment, we added the information and references on the past studies that have been done in Thailand.

“Researchers primarily conducted epidemiological studies, descriptive studies, and clinical studies during the crisis response to the pandemic in Thailand (Lerthattasilp, Kosulwit, Phanasathit et al., 2020; Srifuengfung, Thana-udom, Ratta-apha, Chulakadabba, Sanguanpanich, & Viravan, 2021; Nitchawan, Pantri, Chayut, Yingrat, Nongnuch, & Chotiman , 2022; Suwanbamrung, Pongtalung, Trang, Nam, & Phu, 2023; Phu, 2023). This is quantitative, and the results show the volumes and relationships of factors of all units of analysis in the whole picture. However, qualitative research is needed to provide the nuance, detail, individual problems, and individual needs of COVID-19 patients’ lived reality and contextualized experiences to gain more knowledge and deep understanding to design an advanced nursing intervention, medication-taking style, alternative treatment, and psychosocial intervention. The qualitative research results can provide the clinical information for the new or novel ideas of nursing care that meet this target population’s needs and problems.”

Reference

1. Suwanbamrung, C., Pongtalung, P., Trang, L. T. T., Nam, T. T., & Phu, D. H. (2023). Levels and risk factors associated with depression, anxiety, and stress among COVID-19 infected

adults after hospital discharge in a Southern Province of Thailand. Journal of Public Health

and Development, 21(1), 72-89–89. https://doi.org/10.55131/jphd/2023/210106

2. Srifuengfung, M., Thana-udom, K., Ratta-apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353-365–365. https://doi.org/10.1016/j.jad.2021. 08.044.

3. Nitchawan Kerdcharoen, Pantri Kirdchok, Chayut Wonglertwisawakorn, Yingrat Naviganuntana, Nongnuch Polruamngern, & Chotiman Chinvararak. (2022). Mental health problems of asymptomatic or mildly symptomatic COVID-19 patients in hospitel in Thailand: A cross-sectional study [version 2; peer review: 2 approved]. F1000Research, 11, 1089. https://doi.org/10.12688/f1000research.125998.2

4. Lerthattasilp T, Kosulwit K, Phanasathit M, et al., Psychological impacts on patients with COVID-19 in a Thai field hospital. Arch. Clin. Psychiatry. 2020; 47(6): 215–217.

5. Phu, D. H., Maneerattanasak, S., Shohaimi, S., Trang, L. T. T., Nam, T. T., Suwanbamrung, C., Kuning, M., Like, A., & Torpor, H. (2023). Prevalence and factors associated with long COVID and mental health status among recovered COVID-19 patients in southern Thailand. PLoS ONE, 18(7 July). https://doi.org/10.1371/journal.pone.0289382

3. Theoretical framework - While it is helpful to use a theoretical framework to guide this work, the researchers need to explain how this model is not stifling this study that uses qualitative methods, ensuring that it does not limit creativity or the exploration of alternative perspectives, but rather enhances understanding and provides a structured approach to the research.COMMENTS: There was no response from the authors on this feedback.

Author response: We apologize for the short description of the manuscript’s last version because it related to the APC charge. We have added the suggested content to the manuscript on the theoretical framework parts.

“The Roy adaptation model (RAM) applied this study’s theoretical framework, which deepened our understanding of the lived experiences and the impact of COVID-19 cases. In addition, applying RAM in nursing research will guide the quality of care and provide data to estimate the results. Moreover, RAM is practical to all areas of nursing and frequently applied in the theoretical framework of qualitative studies of COVID-19 cases (Dayılar, Dogan, Güler, & Carroll, 2022).

RAM ( Roy, 2001, 2009, 2011) points out that people are adaptive systems defined as a whole and covered of parts that function as a unit; the whole is influenced by surrounding focal, contextual, and residual stimuli (Roy, 2009). People become resilient by adapting to external environments and internal environments of the individual’s experience (Roy, 2009). The constant change in the environment stimulates people to drive toward adaptive responses, which consist of a) positive responses to stimuli, which are defined as adaptation results in health, both physical and emotional, and b) negative responses, which are defined as maladaptation results in illness. According to RAM, the nursing goal is to promote four adaptive modes of person, thus contributing to the quality of life and health by assessing behaviors and factors that impact adaptive performance and intervening to increase environmental interactions (Roy, 2009). Contextual, focal, and residual stimuli are three environmental stimuli that impact adaptation (Roy, 2009, 2011a). While the focal stimulus is the internal or external stimulus that most impacts and directs an individual’s attention, a contextual stimulus is the internal or external impetus affecting the situation, contributing to the behavior triggered by the focal stimulus (Roy, 2009, 2011a). Contextual stimuli are inferred from a person's events, stressful life events, or illness processes. Residual stimuli are stimuli that are in a person’s internal or external environment. Residual stimuli become contextual or focal once they have been validated by the person experiencing the impact of the stimulus. The adaptive and stimuli are primary elements of understanding individual COVID-19 cases, their adaptation, and their life strategies for enhancing adaptation.”

Reference

1. Dayılar Candan H, Dogan S, Güler C, Carroll K. Roy adaptation model: theory-based

knowledge and nursing care with a person experiencing COVID-19. Nurs Sci Q. 2022; 35(3): 304-310. doi:10.1177/08943184221092434

2. Roy C. (2011a). Research based on the Roy adaptation model: Last 25 years. Nursing Science

Quarterly, 24(4), 312-320. https://doi.org/10.1177/0894318411419218

4.Methods

In the same vein (ie. No. 3), please explain how the interview questions were developed.

COMMENTS: “Third, semi-structured individual in-depth questions were developed by reviewing the literature on the concept of stressful life events, adaptation and emotions. The three validators checked the content and comments.” The authors have added the statement above. As I have commented earlier, “In the same vein (ie. No. 3)” as the authors had used a theoretical framework (as mentioned in No. 3 above), but it is not clear how or where. Was “concept of stressful life events, adaptation and emotions” adapted from the Roy Adaptation Model? If yes, I think some critique and justification are also needed for No. 3 above. Also, this also needs to be explained further how this model was adopted in this study, while using the IPA approach.

This statement can be rephrased to make it clearer. Does it also mean that the authors have designed the interview questions by drawing upon the instrument/findings from these studies? - “The phenomenological-hermeneutic approach was applied through discussions after examining and interpreting lived experiences and perceptions related to the COVID-19 pandemic (Al Kalaldeh et al., 2018; Graor & Knapik, 2013; Kvale & Brinkmann, 2014).”

COMMENTS: The instrument needs to be described. If the questions cannot be shared or published, then a more detailed description of what questions were asked would help.

Author response: Thank you very much. The questions were shared in English version n Figshare: Until the Dawn: The Impact of COVID-19, https://doi.org/10.6084/m9.figshare.21369810 ( Imkome E-u, & Moonchai K, 2022).

“Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Participants (COA No. 119/2563)” - Please state more specifically which committee this refers to e.g. the University of ??? Ethics Review Committee for Research Involving Human Research Participants

COMMENTS: Noted with thanks.

Please state when these interviews were carried out as this is a cross-sectional study.

COMMENTS: No response was given to this suggestion.

Author response: Thank you for pointing this out. A cross-sectional study is another project. We had to remove the sentence from this manuscript.

Please describe how the authors ensured data trustworthiness

COMMENTS: The authors mentioned “Trustworthiness was describing”

in their response to the suggestion. It is not explained how, for example, criteria such as credibility, transferability, dependability or confirmability are ensured. However, the author did mention that “A good rapport, member check, peer debriefing, and researcher triangulation reflect the trustworthiness of this study. The researcher analyzed the transcripts independently using an IPA framework (Smith & Osborn, 2015; Alase, 2017).” Authors could explain these procedures in relation to one or more of the data trustworthiness criteria. It is also helpful to explain how each was carried out i.e. “a good rapport, member check, peer debriefing and researcher triangulation.”

Author response: Thank you very much for your comments. We added the Trustworthiness of the study as the content below:

To ensure data trustworthiness, phenomenological methods such as reflexivity, member checking, and auditing are often among the most highly used procedures to maximize trustworthiness. Member reflections instead of traditional member checking and incorporated peer debriefing to ensure rigor in interpretative qualitative research were used. Feedback and reflections are participant validation of results and an opportunity for further elaboration of findings from participants in the co-construction of the phenomenon with the authors (Flynn & Korcuska, 2018; Smith & McGannon, 2018). Member reflections were primarily incorporated upon completion of the study analysis. All participants were contacted via phone and joined a Microsoft Teams discussion of the summary of the findings.

The authors conducted peer debriefing (Smith & McGannon, 2018) to process the study. The construction of knowledge through critical feedback that encouraged reflection upon and investigation of alternative interpretations emerging from the data was the peer debriefing process that included data collection or analysis and aided in probing the thinking around the research process and analysis (Given, 2008) as weekly during data collection and monthly during data analysis and interpretation.

The trail of the audit was established as initial notes; step-by-step methods for recruitment, data collection, and analysis; annotated transcripts; tables of themes that developed; the final report; and all field notes (J.A. Smith et al., 2022; J. Smith et al., 2009). Field notes recorded details of what was seen, heard, thought, and experienced throughout data collection (Groenewald, 2004). Field notes were divided into four categories, each in separate files. The first was the Interview environment and atmosphere, i.e., objective recordings of what happened, who was involved, what activities occurred, and what was seen or heard. The second was the behavior and the data from the participants. For this process, the notes were recorded immediately after the conclusion of each data collection session. In these notes, the first author documented reflections on personal experiences related to the data and attempts to derive meaning through reflection on the data. The third was obstacles encountered in interviews. The fourth was the planning for the following interview. The final file contained research notes summarizing procedures, events, and study progress.

Reference

1. Flynn SV, Korcuska JS. Credible Phenomenological Research: A Mixed‐Methods Study. Couns Educ Superv. 2018; doi.org/10.1002/ceas.12092.2

2. Smith B, McGannon KR. Developing rigor in qualitative research: problems and opportunities within sport and exercise psychology. Int Rev Sport Exerc Psychol. 2018; doi.org/10.1080/1750984x.2017.1317357.

3. Given LM. The SAGE Encyclopedia of Qualitative Research Methods. SAGE Publications, Inc. eBooks. 2008; doi.org/10.4135/9781412963909.

4. Smith JA, Flowers P, Larkin M. Interpretative Phenomenological analysis: Theory, Method and Research. SAGE; 2022.

5. Smith JA, Flowers P, Larkin M. Interpretative Phenomenological analysis: Theory, Method and Research. SAGE Publications; 2009.

Please provide support and justification for the data analysis methods employed.

COMMENTS: As procedures were using the IPA framework, how was the Roy Adaptation Model

Author response: Thanks for the interesting query. The Roy Adaptation Model was applied as the theoretical framework for this study.

Results

Table 1 - The marital status “Couple” means living with a partner or married?

COMMENTS: “Table 1 - The marital status “Couple” means living with a partner and/or married.

Noted with thanks. This makes it clearer.

Level 1 - It would be helpful to describe the results found about the respondents Self-Understanding.

COMMENTS: No response provided. No explanation is found in the paper.

Author response: We added the results found about the respondents' Self-Understanding below:

“All participants show physical survival during the interview. The participant has a low level of psychic integrity. They have stress, fear, anxiety, communication problems, sleep problems, and poor decision-making. Some of them have no job or have lost a job. However, they receive social support from significant others and health care providers.”

Is Figure 1 showing the results of this study? What does this statement mean - “Apply from Roy, 2011”? There may be a typo or grammatical mistake here.

COMMENTS: No response provided

Author response: Thank you very much. It is a typo. We removed it from the manuscript.

It is not clear why the Results of the analysis are labelled as “Level”. This is not a conventional way to report the results of a qualitative study. Labelling each theme/category as a “level” indicates a hierarchy. Is this the intention, if so, the hierarchy is not clear.

COMMENTS: No response provided.

Author response: Thank you for your comment. We intended to label the analysis results as “Level,” which starts with general data, structural understanding, and Theoretical interpretation. Please provide your idea to make this manuscript more straightforward.

The sub-themes in Level 2 appears confusing. From the formatting of the paper, it appears that within “Level 2: Structural understanding”, there are Stress; Economic and Social Impact; Social Stigma; Social Support; Sometimes, bad luck brings good luck. Are these sub-themes all of the same level sub-themes under “Level 2”? Or are some of them of a third level sub-theme?

Author response: Thank you very much. All the themes that you mention are the sub-themes of level 2. Structural understanding, a major theme derived from content analysis, was evident across interviews and included stress, economic and social impact, social stigma, and the concept that bad luck occasionally brings good luck.

-------------------------------------------------------------------------------------------------------------

Imkome

Ek-uma

Competing interests: No competing interests were disclosed.

30 4 2025

Reviewer’s comments:

Because this study was done in Thailand, it is helpful to describe the situation there during the pandemic to help readers understand the context in which this study was based.

Author response:

We have strengthened the contextual description of the COVID-19 pandemic in Thailand by incorporating relevant references that document the psychological and social challenges faced by patients during this period. Specifically, we have cited studies that examine the impact of quarantine, fear, loneliness, and anxiety on individuals, as well as research addressing concerns about infecting family and community members. These references provide empirical support for our discussion and enhance the credibility of our findings.

Furthermore, we have refined the narrative to ensure that the contextual background is presented with clarity and conviction. By integrating these references, we aim to provide a more comprehensive understanding of the environment in which our study was conducted, thereby reinforcing the methodological integrity of our research.

Reviewer’s comments

2. The knowledge gap needs to be further established and supported to justify the need for this investigation and the significance of this study.

a. It is important that the researchers provide support for this statement - "Besides, a few studies have explored the needs of COVID-19 cases, their stress and adaptation to the disease, and health support."

b. In this regard, it would also be appropriate to refer to past studies that have been done in Thailand, as well as in other countries to establish the need to conduct this investigation and fill this knowledge gap.

Author response:

Thank you for your insightful feedback. We have revised the manuscript accordingly to strengthen the justification for this study and establish the knowledge gap more clearly in the introduction parts.

Reviewer’s comments:

Author response:

We have revised the manuscript to clarify how the application of the Roy Adaptation Model (RAM) enhances understanding rather than limiting creativity or alternative perspectives. The revisions ensure that RAM is used as a guiding framework that supports qualitative inquiry without restricting the emergence of diverse themes and lived experiences.

In the Theoretical Perspective section, we now explicitly discuss how RAM provides structure for interpreting psychosocial adaptation while maintaining flexibility in exploring participants' unique narratives. Rather than prescribing rigid categories, RAM serves as an interpretive lens that allows for thematic development and multidimensional analysis, ensuring that the phenomenological nature of the study remains intact.

We have emphasized that our phenomenological-hermeneutic approach fosters open-ended exploration, allowing themes to emerge organically from participants’ lived experiences. The use of RAM helps categorize adaptation processes without stifling creativity, ensuring that alternative perspectives, such as unexpected benefits and resilience factors, are fully captured.

Reviewer’s comments:

4. Methods

a. In the same vein (ie. No. 3), please explain how the interview questions were developed.

Also, this also needs to be explained further how this model was adopted in this study, while using the IPA approach.

Author response:

We have updated the manuscript to provide a detailed explanation of the development of interview questions, including specific examples, and their foundation in both existing literature and the Roy Adaptation Model (RAM) within the Procedures section.

Reviewer’s comments:

b.This statement can be rephrased to make it clearer. Does it also mean that the authors have designed the interview questions by drawing upon the instrument/findings from these studies? - "The phenomenological-hermeneutic approach was applied through discussions after examining and interpreting lived experiences and perceptions related to the COVID-19 pandemic ( Al Kalaldeh et al., 2018; Graor & Knapik, 2013; Kvale & Brinkmann, 2014)."

COMMENTS: The instrument needs to be described. If the questions cannot be shared or published, then a more detailed description of what questions were asked would help.

Author response:

We are providing a more detailed description of the specific questions asked during the interviews. While we may not be able to share the exact questions due to confidentiality concerns, we have included a sample of the questions in the Procedures section.

Reviewer’s comments:

c. "Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Participants (COA No. 119/2563)" - Please state more specifically which committee this refers to e.g. the University of ??? Ethics Review Committee for Research Involving Human Research Participants

Author response:

We have added the following information regarding ethical approval:

"This project was approved by the Human Research Ethics Committee of Thammasat University (Science), Thailand (COA No. 119/2563). The research adhered to ethical standards established by the Institutional Review Board (IRB) and the Helsinki Declaration (2000). Prior to obtaining informed consent, all participants were informed about the study's objectives, the safe protection of their data, and the associated risks and benefits. Participants were made aware of their right to withdraw from the study at any time.

Written informed consent was obtained from all participants before data collection commenced. Participation in the study was entirely voluntary, and the anonymity of participants was maintained throughout the research process. Confidentiality strategies were implemented, and identifying codes were assigned to the initial data collected from observations, interviews, and documentary analyses; access to this data was restricted to the research team.

The data were securely stored on the principal investigator's password-protected computer until the conclusion of the study. After 24 months, all files were permanently deleted using “Secure Deletion Shredder,” a protected deletion program for Windows."

Reviewer’s comments:

d. Please state when these interviews were carried out as this is a cross-sectional study.

Author response:

We sincerely appreciate the reviewer’s comment and would like to apologize for any confusion caused. We would like to clarify that this study is purely qualitative and does not utilize a cross-sectional design. The mention of "cross-sectional" was an unintentional typographical error.

Reviewer’s comments:

e.Please describe how the authors ensured data trustworthiness

COMMENTS: The authors mentioned “Trustworthiness was describing”

Author response:

We appreciate the reviewer’s valuable feedback and have revised the manuscript to provide a detailed of Trustworthiness on the Trustworthiness parts.

Reviewer’s comments:

5. Please provide support and justification for the data analysis methods employed.

COMMENTS: As procedures were using the IPA framework, how was the Roy Adaptation Model

Author response:

Thank you for your valuable feedback. We appreciate the opportunity to clarify the rationale behind our data analysis approach. To address this, we have incorporated the following explanation:

Our analytical framework was structured into progressive levels to capture the evolving adaptation trajectory of participants. Level 1 focused on self-perception and emotional responses, serving as the foundation for subsequent thematic development. Level 2 explored structural influences, such as stigma and social support, which shaped individual coping strategies. Finally, Level 3 integrated adaptation strategies within the broader theoretical framework, ensuring a multidimensional perspective without imposing hierarchical constraints.

Reviewer’s comments:

6. Results

a. Table 1 - The marital status "Couple" means living with a partner or married?

COMMENTS: “ Table 1 - The marital status "Couple" means living with a partner and/or married.

Noted with thanks. This makes it clearer.

Author response:

Thank you for your acknowledgment. We appreciate your review and are glad the clarification helps improve the understanding of our study.

Reviewer’s comments:

b. Level 1 - It would be helpful to describe the results found about the respondents Self-Understanding.

Author response:

Thank you for your feedback. We appreciate the opportunity to clarify our findings.

At Level 1 analysis, self-understanding captures participants' perceptions of their experiences with COVID-19. Respondents reported psychological distress—stress, anxiety, sleep disturbances, and impaired decision-making—exacerbated by financial instability and job loss. Social support played a critical role in moderating emotional strain, with individuals who engaged support systems demonstrating greater psychological stability.

Self-understanding evolved throughout their adaptation process. Some participants recognized personal resilience, while others struggled with stigma and reintegration. By analyzing this dimension, our study highlights the need for psychosocial interventions that foster emotional resilience and facilitate long-term recovery.

We hope this addresses your concerns and strengthens the discussion in our manuscript.

Reviewer’s comments:

c. Is Figure 1 showing the results of this study? What does this statement mean - "Apply from Roy, 2011"? There may be a typo or grammatical mistake here.

Author response:

Thank you for your review. "Apply from Roy, 2011" was a typographical error.

Reviewer’s comments:

d. It is not clear why the Results of the analysis are labelled as "Level". This is not a conventional way to report the results of a qualitative study. Labelling each theme/category as a "level" indicates a hierarchy. Is this the intention, if so, the hierarchy is not clear.

Author response:

Thank you for your feedback. The use of "Level" in our analysis aligns with the Interpretative Phenomenological Analysis (IPA) framework, which emphasizes a layered, progressive interpretation of participants' lived experiences. The "Level" structure moves from descriptive self-understanding (Level 1) to thematic development (Level 2) and theoretical interpretation (Level 3). This approach ensures a deeper exploration of adaptation processes while maintaining methodological rigor. It does not imply a rigid hierarchy but reflects a structured analytical progression.

Reviewer’s comments:

e. The sub-themes in Leval 2 appears confusing. From the formatting of the paper, it appears that within "Level 2: Structural understanding", there are Stress; Economic and Social Impact; Social Stigma; Social Support; Sometimes, bad luck brings good luck. Are these sub-themes all of the same level sub-themes under "Level 2"? Or are some of them of a third level sub-theme?

Author response:

Thank you for your feedback. We appreciate the opportunity to clarify the organization of sub-themes within "Level 2: Structural Understanding."

All sub-themes—Stress, Economic and Social Impact, Social Stigma, Social Support, and Sometimes, Bad Luck Brings Good Luck—are of the same level within Level 2. They represent distinct dimensions of participants’ experiences and adaptation during the pandemic and were identified through thematic analysis.

The hierarchical structure of the results is based on the Interpretative Phenomenological Analysis (IPA) framework, where Level 1 focuses on individual self-understanding, Level 2 develops structural themes from shared experiences, and Level 3 applies theoretical interpretation using the Roy Adaptation Model. Within Level 2, the sub-themes were derived from content analysis and do not represent further subdivisions but rather interconnected aspects of adaptation processes.

-------------------------------------

10.5256/f1000research.155443.r209257

Reviewer response for version 2

Srichannil

Chomphunut

1 Referee 1Department of Psychology, Chulalongkorn University, Bangkok, Bangkok, Thailand

Competing interests: No competing interests were disclosed.

2 10 2023

2023

recommendation

reject

In this revised article, more information about the research procedures have been provided but it appears that this research still lacks methodological consistency and accuracy. It remains unclear what methodology has actually been used in this research. Although IPA (Interpretative phenomenological analysis) was added in this version, the data analysis, quality criteria, as well as the reporting of research findings do not align with IPA. Due to the significant lack of methodological rigor of this paper, it is not approved.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

No source data required

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Counseling Psychology

Imkome

Ek-uma

Competing interests: I declare that the authors have no competing interests as defined by F1000Resesarch, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

16 1 2024

We want to thank you for your insightful comment. We hope that with your comments, our manuscript will meet the high standards of F1000Research. We provide a response below.

Introduction parts

1.1 We added information and the references were addressed as the list below:

"During the COVID-19 pandemic in Thailand, people have faced problems such as stress, fear, loneliness, boredom, anger, anxiety, insomnia, a feeling of taboo, and low health literacy (Suwanaphant et al., 2020; Choompunuch et al., 2021; Boondiskulchok et al., 2022; Suanrueang et al., 2022; Taweewun et al., 2022). Moreover, people have also been concerned about the effect of being quarantined on their psychological well-being, acute health conditions, the risk of infecting family members and community members, and the sorrows and worries that influence jobs and income (Yongthasaneekul & Thammaboosadee, 2021; Wongtanasarasin, Srisawang, Yothiya, & Phinyo, 2021; Hall, Sanchez, Da, Bennett, Powers, & Warren, 2022)".

References

1. Taweewun Srisookkum, Somkid Juwa, Orathai Katkhaw, Tienthong Takaew, Saengduean

2. Suanrueang P, Suen MW, Lin HF, Er TK, Michaela M, Jamora Q. The impact of the covid-19 pandemic on anxiety, health literacy, and eHealth literacy in 2020 related to healthcare

behavior in Thailand. J Public Hlth Dev. 2022;20(1):188-202. doi:10.55131/jphd/ 2022/

200115.

1.2 we added the information and references on the past studies that have been done in Thailand.

"Researchers primarily conducted epidemiological studies, descriptive studies, and clinical studies during the crisis response to the pandemic in Thailand (Lerthattasilp, Kosulwit, Phanasathit et al., 2020; Srifuengfung, Thana-udom, Ratta-apha, Chulakadabba, Sanguanpanich, & Viravan, 2021; Nitchawan, Pantri, Chayut, Yingrat, Nongnuch, & Chotiman , 2022; Suwanbamrung, Pongtalung, Trang, Nam, & Phu, 2023; Phu, 2023). This is quantitative, and the results show the volumes and relationships of factors of all units of analysis in the whole picture. However, qualitative research is needed to provide the nuance, detail, individual problems, and individual needs of COVID-19 patients' lived reality and contextualized experiences to gain more knowledge and deep understanding to design an advanced nursing intervention, medication-taking style, alternative treatment, and psychosocial intervention. The qualitative research results can provide the clinical information for the new or novel ideas of nursing care that meet this target population's needs and problems."

Reference

1. Suwanbamrung, C., Pongtalung, P., Trang, L. T. T., Nam, T. T., & Phu, D. H. (2023). Levels and risk factors associated with depression, anxiety, and stress among COVID-19 infected

adults after hospital discharge in a Southern Province of Thailand. Journal of Public Health

and Development, 21(1), 72-89–89. https://doi.org/10.55131/jphd/2023/210106

4. Lerthattasilp T, Kosulwit K, Phanasathit M, et al., Psychological impacts on patients with COVID-19 in a Thai field hospital. Arch. Clin. Psychiatry. 2020; 47(6): 215–217.

2. Theoretical framework We apologize for the short description of the manuscript's last version because it related to the APC charge. We have added the suggested content to the manuscript on the theoretical framework parts.

"The Roy adaptation model (RAM) applied this study's theoretical framework, which deepened our understanding of the lived experiences and the impact of COVID-19 cases. In addition, applying RAM in nursing research will guide the quality of care and provide data to estimate the results. Moreover, RAM is practical to all areas of nursing and frequently applied in the theoretical framework of qualitative studies of COVID-19 cases (Dayılar, Dogan, Güler, & Carroll, 2022).

RAM ( Roy, 2001, 2009, 2011) points out that people are adaptive systems defined as a whole and covered of parts that function as a unit; the whole is influenced by surrounding focal, contextual, and residual stimuli (Roy, 2009). People become resilient by adapting to external environments and internal environments of the individual's experience (Roy, 2009). The constant change in the environment stimulates people to drive toward adaptive responses, which consist of a) positive responses to stimuli, which are defined as adaptation results in health, both physical and emotional, and b) negative responses, which are defined as maladaptation results in illness. According to RAM, the nursing goal is to promote four adaptive modes of person, thus contributing to the quality of life and health by assessing behaviors and factors that impact adaptive performance and intervening to increase environmental interactions (Roy, 2009). Contextual, focal, and residual stimuli are three environmental stimuli that impact adaptation (Roy, 2009, 2011a). While the focal stimulus is the internal or external stimulus that most impacts and directs an individual's attention, a contextual stimulus is the internal or external impetus affecting the situation, contributing to the behavior triggered by the focal stimulus (Roy, 2009, 2011a). Contextual stimuli are inferred from a person's events, stressful life events, or illness processes. Residual stimuli are stimuli that are in a person's internal or external environment. Residual stimuli become contextual or focal once they have been validated by the person experiencing the impact of the stimulus. The adaptive and stimuli are primary elements of understanding individual COVID-19 cases, their adaptation, and their life strategies for enhancing adaptation."

Reference

1. Dayılar Candan H, Dogan S, Güler C, Carroll K. Roy adaptation model: theory-based

knowledge and nursing care with a person experiencing COVID-19. Nurs Sci Q. 2022; 35(3): 304-310. doi:10.1177/08943184221092434

2. Roy C. (2011a). Research based on the Roy adaptation model: Last 25 years. Nursing Science

Quarterly, 24(4), 312-320. https://doi.org/10.1177/0894318411419218

3. MethodsWe added more detail of the Roy Adaptation Model in the theoretical framework. Stressful life events, adaptation, and emotions were also mentioned. Additionally, we added the Trustworthiness of the study as the content below:

Reference

1. Flynn SV, Korcuska JS. Credible Phenomenological Research: A Mixed‐Methods Study. Couns

Educ Superv. 2018; doi.org/10.1002/ceas.12092.2

2. Smith B, McGannon KR. Developing rigor in qualitative research: problems and opportunities

within sport and exercise psychology. Int Rev Sport Exerc Psychol. 2018; doi.org/10.1080/1750984x.2017.1317357.

3. Given LM. The SAGE Encyclopedia of Qualitative Research Methods. SAGE Publications, Inc. eBooks. 2008; doi.org/10.4135/9781412963909.

4. Smith JA, Flowers P, Larkin M. Interpretative Phenomenological analysis: Theory, Method and

Research. SAGE; 2022.

5. Smith JA, Flowers P, Larkin M. Interpretative Phenomenological analysis: Theory, Method and

Research. SAGE Publications; 2009.

6. Results We added the results found about the respondents' Self-Understanding below:

"All participants show physical survival during the interview. The participant has a low level of psychic integrity. They have stress, fear, anxiety, communication problems, sleep problems, and poor decision-making. Some of them have no job or have lost a job. However, they receive social support from significant others and health care providers."

Imkome

Ek-uma

Competing interests: No competing interests were disclosed.

30 4 2025

Thank you for your feedback and for taking the time to review our manuscript. We appreciate your insights and recognize the importance of methodological consistency in qualitative research.

In this revised version, we have taken additional steps to clarify the methodology used in our study. Specifically, we employed a phenomenological-hermeneutic approach to analyze the lived experiences of our participants.

Our data analysis adhered to Smith and Osborn's (2015) Interpretative Phenomenological Analysis (IPA) framework. This process involved an iterative cycle of coding that progressed from descriptive to interpretative engagement, ensuring that emergent themes were grounded in participants' lived experiences. We employed bracketing techniques to minimize researcher bias and utilized double-coding verification to enhance reliability. The initial codes were generated based on descriptive responses, then refined through interpretative layers to derive emergent themes, ensuring alignment with IPA principles.

Regarding methodological rigor, we have provided more explicit details on the data analysis process, including the use of COREQ guidelines to enhance transparency. Additionally, we have improved the explanation of quality criteria and ensured that our approach maintains consistency in its application.

10.5256/f1000research.140098.r193387

Reviewer response for version 1

Kin

Cheah Phaik

1 Referee https://orcid.org/0000-0002-2615-5217 1Faculty of Arts and Social Science, Universiti Tunku Abdul Rahman, Petaling Jaya, Selangor, Malaysia

Competing interests: No competing interests were disclosed.

7 8 2023

2023

recommendation

reject

Because this study was done in Thailand, it is helpful to describe the situation there during the pandemic to help readers understand the context in which this study was based.

The knowledge gap needs to be further established and supported to justify the need for this investigation and the significance of this study.

Methods

In the same vein (ie. No. 3), please explain how the interview questions were developed.

Please state when these interviews were carried out as this is a cross-sectional study.

Please describe how the authors ensured data trustworthiness.

Please provide support and justification for the data analysis methods employed.

Results

Table 1 - The marital status "Couple" means living with a partner or married?

Level 1 - It would be helpful to describe the results found about the respondents Self-Understanding.

Is Figure 1 showing the results of this study? What does this statement mean - "Apply from Roy, 2011"? There may be a typo or grammatical mistake here.

Overall, while the purpose of this paper is rationale and very necessary, this paper lacks the scientific rigour. I would recommend a resubmission.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Public Health, education, policing

Imkome

Ek-uma

Competing interests: No competing interests were disclosed.

31 8 2023

This version has addressed reviewer 2's comments by:

Adding the statement of the situation during the COVID-19 pandemic in Thailand,

the gap of knowledge was address and citation

Adding an explanation of how the interview questions were developed.

rephrased the statement to make it clearer on the part of procedure

Added the state of the Ethics Review Committee’s institution

Trustworthiness was describing

The IPA analysis methods were employed

Table 1 - The marital status "Couple" means living with a partner and/or married.

10.5256/f1000research.140098.r175113

Reviewer response for version 1

Srichannil

Chomphunut

1 Referee 1Department of Psychology, Chulalongkorn University, Bangkok, Bangkok, Thailand

Competing interests: No competing interests were disclosed.

20 6 2023

2023

recommendation

approve-with-reservations

This study used online interviews to explore the lived experiences of 15 COVID-19 survivors, focusing on the impact of COVID-19.

Data Collection

Data saturation was mentioned, but it is not clear how saturation was reached. Indeed, the question should also be extended to “Is data saturation required for using phenomenological-hermeneutic approach?”

In terms of recording online video interviews, there should be more information regarding how the issues of confidentiality, data storage, and data safety have been addressed.

Data Analysis

There is an inconsistency in mentioning the use of the methods for analyzing the data in the abstract and other sections. Specifically, in the abstract, the authors stated that “using a phenomenological-hermeneutic approach. We used the thematic analysis technique to analyze the data”. (The use of “thematic analysis technique” could also be confused with Thematic Analysis, a range of methods for qualitative data analysis). In the data analysis section, only the phenomenological-hermeneutic approach was stated (Here a citation to “Kvale & Brinkmann, 2014” was claimed, but this was not on the reference list). However, content analysis was also mentioned in the result section when the authors wrote “Major themes derived from content analysis were evident across interviews”. The question is thus what is the data analysis method used in the study? Additionally, the word “structural understanding” appeared to be redundant in the second and third levels. Please check for accuracy.

Results

It appears that the results were fairly descriptive, mostly done by presenting (translated) quotes from the participants. With the use of the phenomenological-hermeneutic approach, interpretation should be more widely incorporated in the results.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

No source data required

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Counseling Psychology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Imkome

Ek-uma

Competing interests: No competing interests were disclosed.

31 8 2023

To respond to the reviewer's comments on Data Collection.

We added the sentence “the saturation was reached when no additional data were found” on the part of data collection. Additionally, we had to add more information regarding how the issues of confidentiality, data storage, and data safety have been addressed on the part of consent. We have updated Kvale & Brinkmann, 2014 as the reference, and The IPA analysis methods were added.

We removed the redundant “structural understanding” in the second and third levels for the results and corrected it for the data analysis part.