|Year : 2021 | Volume
| Issue : 2 | Page : 99-106
Community surveillance of COVID-19 pandemic: Perspectives and experiences of medical trainees using mixed-methods research design
R Anil, B A Praveen Kumar, S Srikanth, NJ Priyadarisini, P Janakiraman, M Devivaraprasad, P Subramaniyan, Chitra Nagaraj
Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
|Date of Submission||09-Oct-2020|
|Date of Acceptance||01-Feb-2021|
|Date of Web Publication||29-Jun-2021|
Dr. B A Praveen Kumar
Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam - 517 425, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: COVID-19 is an ongoing pandemic and a global public health crisis. India has been setting up multiple strategies to contain this pandemic. Active community-level surveillance is a vital strategy to prevent, control, and manage the outbreak of COVID-19. This study explores the perspectives and describes budding doctors' field experience who worked in the community surveillance activity during the pandemic.
Materials and Methods: We used a mixed-method research design wherein 67 medical interns of a tertiary care teaching institute participated in the COVID-19 pandemic surveillance activity were included in the study. Their field experience, perspectives, and opinions were captured using pretested questionnaires, participants' interviews, and focused group discussions.
Results: More than one-third of medical interns (41.8%) felt that the government could better handle the surveillance process, while around two-thirds (65.6%) were satisfied with their work. Notably, 40 (59%) were not happy/clear with the training and orientation on the job before engaging in surveillance activity. A majority of 47 (70.1%) interns reported inadequate personal protective equipment, which raised the fear of transmission. While they felt that surveillance provided health services close to the community and addressed the public's pandemic concerns, they said the lack of basic training, an inadequate workforce, and resources were detrimental to the response.
Conclusions: This pandemic has exposed the naive interns to the community health surveillance process's ground realities. This experience has changed their perception of the profession and given them the impetus to become a future workforce. Strength, weaknesses, opportunities, and threats analysis of the surveillance process provided vital inputs to act and prepare for future public health emergencies.
The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, Interpersonal and communication skills, and Professionalism.
Keywords: Epidemic, medical interns, public health emergency, strength, weaknesses, opportunities, and threats analysis
|How to cite this article:|
Anil R, Kumar B A, Srikanth S, Priyadarisini N J, Janakiraman P, Devivaraprasad M, Subramaniyan P, Nagaraj C. Community surveillance of COVID-19 pandemic: Perspectives and experiences of medical trainees using mixed-methods research design. Int J Acad Med 2021;7:99-106
|How to cite this URL:|
Anil R, Kumar B A, Srikanth S, Priyadarisini N J, Janakiraman P, Devivaraprasad M, Subramaniyan P, Nagaraj C. Community surveillance of COVID-19 pandemic: Perspectives and experiences of medical trainees using mixed-methods research design. Int J Acad Med [serial online] 2021 [cited 2022 Aug 17];7:99-106. Available from: https://www.ijam-web.org/text.asp?2021/7/2/99/319797
| Introduction|| |
The COVID-19 pandemic, with 25 million cases and 0.8 million deaths worldwide, as of September 2020, is an ongoing public health crisis and currently the top-most researched area. India, one of the severely hit countries by the number of cases was swift in setting up strategies to contain this pandemic. Trace, Quarantine, Test, Isolate, and Treat has been one of the strategies in India. Several states are also adapting their own innovations and approaches while following the national guidelines.
Public health surveillance is an “ongoing systematic collection, analysis, and interpretation of data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease and injury.” Timely surveillance provides evidence that, in turn, empowers the stakeholders to make timely decisions to act upon the given situation.
A public health emergency, especially the COVID-19 pandemic, is a challenge to every health system, whether in a developed or developing setting. Understanding the realities of community surveillance during the pandemic becomes very important as it helps us to be prepared for the future accordingly. Lessons learned from containment and surveillance activities during previous epidemics and pandemics (influenza A H1N1, MERS CoV, Nipah Virus, and Ebola virus) highlight the importance of the public health systems at the forefront to bail-out the world from tragic events.,,,, Global surveillance for COVID-19 in humans is the need of the hour. It includes (a) monitoring the trends of COVID-19, (b) active case finding, and (c) providing epidemiological information to conduct a risk assessment and to guide preparedness and response measures. Only active surveillance provides the early warning information that leads to a dynamic response to an epidemic.
The Government of India has formulated the Micro Plan for Containing Local Transmission of Coronavirus Disease (COVID-19) with tasks and roles at each administrative level. The State of Andhra Pradesh has issued further guidelines for conducting surveillance and containing the infection., The Government of Andhra Pradesh has adopted a multilevel surveillance strategy to control this pandemic. The District Collectorate was designated as the nodal center for containment at the district level and was responsible for all the subdistrict level activities.
The Government of Andhra Pradesh undertook massive community-level surveillance by utilizing all the health workforce in the state. Bachelor of Medicine, Bachelor of Surgery (MBBS.) Interns (trainees on Compulsory Rotatory Internship) from a tertiary care teaching institute, Andhra Pradesh, were also made a part of this mandatory public health activity. This new batch of interns, just beginning their internship, never had the experience of a pandemic of this scale. Hence, capturing their field experiences in COVID-19 mitigation efforts will help us to understand their aptitude and adaptability. This study explores the perspectives and describes the field experience of budding doctors who worked in the community surveillance activity during a pandemic.
| Materials and Methods|| |
The Government of Andhra Pradesh utilized the services of MBBS interns to supplement the human resources required during the crisis. A tertiary care teaching institute received a request letter from District Medical and Health Office (DM & HO), Chittoor, Andhra Pradesh, to depute medical interns for “Ward Surveillance” duty.
Accordingly, 67 new MBBS interns were deputed to the DM & HO for surveillance activities. These interns were posted to four regions of Andhra Pradesh state – Kuppam (eight interns), Chittoor (28 interns), Madanapalle (11 interns), and Srikalahasti (20 interns) in the Health Surveillance Team under the Medical Officers-in-charge. Their posting period was for 10 days initially and then extended by another 20 days. They had a formal meeting with the respective Municipal Commissioner and Medical Officers on their first day. The interns were given an orientation to the COVID-19 situation in their allotted regions and the duties to perform. The activities undertaken by our interns were as follows:
- Providing basic health-care counseling and services to the people in the allotted region
- Reporting to the Medical Officer if the Primary Health Surveillance team had identified any probable cases
- Visiting the houses of the people who had recently traveled from other places and counseling them to be on home quarantine
- Submitting the data/information to the higher authorities in the prescribed format.
A mixed-method research design (Qualitative and Quantitative) was carried out. Qualitative methods where participants' interviews and focused group discussions were studied. A quantitative method wherein a cross-sectional survey was carried out among them.
This study was conducted from June to July 2020.
Study population and inclusion criteria
The medical (MBBS) interns who had attended the COVID-19 community surveillance activity of Andhra Pradesh state and were willing to participate in the study.
The purposive sampling was used.
The sample size was 67.
The research team and reflexivity
The three interviewers who conducted the interviews and focused group discussions were specialized in MD Community Medicine with at least 3 years of experience working in the field activities or previous community surveillance work. The interviewers were faculty in the institution at the time of the study, and the participants were former students during their academic subjects in the MBBS course. Before the study, neither the participants nor the investigators had assumptions or interests in this research topic.
Method of collection
Part I – A brief face-to-face interview was conducted at the workplace for all the medical interns to capture their perceptions and experiences. Based on interview transcripts, common nodes and themes were synthesized, followed by a pretested semi-structured self-administered questionnaire upon their agreement.
Part II – Six focused group discussions with 8–12 participants were conducted on groups representing four regions. Their observations and opinions were recorded on a structured model, which was synthesized in the previous step. In the end, final transcripts were given to participants for their comments and validation.
Microsoft office 2019 was used for data entry and analysis. Quantitative data were represented using proportions and percentages. Content and critical analysis of qualitative data were carried out manually based on the transcripts. Investigators identified the common codes, inductive coding followed by thematic synthesis were presented. Methodological and data triangulation was done to ensure data credibility and validity.
Research ethics and scientific integrity statement
Approval was obtained from the Institutional Human Ethics Committee of the institute where the study was carried out (Approval No. PESIMSR/IHEC/203 dated June 30, 2020). Informed consent was obtained from the participants before enrollment. The anonymity of participants is ensured, and identity has not been revealed in the manuscript.
| Results|| |
All 67 interns who carried out the surveillance activity for the government participated in this study. There were 24 (35.8%) boys and 43 (64.2%) girls aged between 22 and 25 years.
Perception of posting
When the compulsory surveillance deputation was announced, most of the interns, 43 (64.1%), felt neutral, and 17 (25.3%) were happy and willing to participate. However, many reported that their parents, 28 (41.7%) were apprehensive and objected to posting for community surveillance activity during the pandemic.
Perception of the government's efforts to provide logistics/facilities for interns
The Government of Andhra Pradesh arranged travel, food, and accommodations. A majority, 47 (70.2%), of the interns felt that the transportation facilities were good. In contrast, almost half of them believed the food and accommodation (46.2% and 44.8%) could have been better. When asked about how the situation was handled, 22 (32.8%) and 28 (41.8%) of the interns felt that the college and government, respectively, could have made their experience better during their community surveillance posting [Figure 1] and [Figure 2].
|Figure 1: Perception of interns with regard to facilities provided by the government (n = 67)|
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|Figure 2: Perception of interns regarding their experience of being handled by the college and government during the surveillance activity (n = 67)|
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As they started their surveillance duties, 40 (59.7%) interns felt that the municipality office's orientation on their role and responsibilities in the field was not clear, and they were not satisfied by it. A majority of 47 (70.1%) interns said that they were not provided with adequate personal protective equipment (PPE) to work in the field [Figure 3].
|Figure 3: (a) Perception on orientation provided on job responsibility before surveillance activity and (b) perception on the adequacy of personal protective equipment provided by the government (n = 67)|
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Perception of reception
Initially, most of the interns, 55 (82.1%), felt that the public received them well. Twenty-four (32.8%) of the interns reported that the people's responses became irritated and hostile on repeated follow-ups [Figure 4].
|Figure 4: Comparison of public response to the interns during their field visits at the beginning and toward the end of community surveillance (n = 67)|
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Perception of extension
At the beginning of their posting, they were posted only for 10 days, and later on, it was extended by another 20 days. This extension did not go down well, with almost a quarter of the interns (25.3%) as they felt dejected at that moment [Table 1].
|Table 1: Responses to the questions probing the mental state of interns posted for community surveillance (n=67)|
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Overall experience and satisfaction
At the end of the surveillance, more than half of the interns, 39 (58.2%), enjoyed their work entirely, and 44 (65.6%) had a sense of accomplishment and satisfaction. The highlight of community surveillance was that it changed the perception of the majority of interns 48 (71.6%) toward the medical profession in a positive way [Table 1].
Qualitatively, selected excerpts, and verbatim quotes from the interviews and focused group discussions are presented here:
Perception of overall activity and work satisfaction
Interns felt proud to become doctors, a sense of accomplishment, and self-confidence. They overlooked the shortfalls of the process and developed a passion for the profession, especially community activities.
Many interns said that it was an “eye-opening experience” for them to work during a pandemic and that they were “impressed by the efforts” of grass-root front-line workers. They recognized the value of the “community workforce”, and said that their “respect towards the healthcare workers has increased.”
Opinion and experience on personal protective equipment
Interns were provided with only “cloth masks” and of “low quality” and did not have other masks to protect themselves in high-risk scenarios. They did not have an adequate supply of hand sanitizers. Four interns said they “refused to enter the municipal office” at a point during their work since “the premises had COVID cases” and because they “did not have proper PPE.”
Opinion and experience in transport, lodging, and food provided
Interns were “happy with the transport arrangements.” Interns representing two regions described their living arrangements experience as “very bad lodging” and “rooms in poor condition.” They also experienced “suffocation” as the rooms were poorly ventilated with “lots of dust and mosquitoes.” Lady interns felt “unsafe” in the living arrangements as the lighting in their rooms was low, and nobody around to talk or seek help if needed. They expressed their concerns to supervisors/caretakers on several occasions during the period as “we cannot stay here.”
One of the interns said, “rooms were very hot. I could not sleep properly, and I used to wake up in the middle of the night.” Many interns insisted on being provided air conditioned accommodations, which was not done.
Interns felt “food was not satisfying,” and food handlers did not follow adequate food hygiene and safety measures.
When COVID-19 positive patients were lodged on the same premises as the interns, they were “scared and anxious.” They were regularly communicating with their supervisors to get them “relieved from the surveillance duties.”
Perception of interns parents
Many interns reported that their parents insisted on “returning to college” when they were mid-way through the posting, and interns also wanted to “come back to college.”
Opinions and interns' experiences were analyzed, and the most common strength, weaknesses, opportunities, and threats (SWOT) of the community surveillance activity are reported as a SWOT analysis [Table 2].
|Table 2: Strengths, weaknesses, opportunities, threats/challenges analysis of coronavirus disease -19 community surveillance activity as per the intern's experience and responses|
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| Discussion|| |
The medical interns who were posted for the surveillance duty had just completed their final phase of the MBBS course and had no experience directly handling patients in the hospital or the community. Like many of their peers, they had never experienced a pandemic in their lifetime. Therefore, it is understandable that they were taken aback after being posted for the COVID-19 surveillance duty within their internship's first 10 days. Nevertheless, 64.1% of the were not excited about their posting to COVID-19 pandemic surveillance activities. The reason for this might have been that most of them had a fear of getting exposed to the infection. Furthermore, there was veiled excitement to start their internship with this pandemic adventure. The mindset of becoming interns and future health professionals was an achievement for them, and this duty only increased their pride in becoming doctors. This mixed response by interns in our study was similar to the study conducted by Shanafelt et al., which reported that health-care professionals greater risk of getting exposed, extreme workloads, moral dilemmas, and an unfamiliar environment could be some of the reasons for their trepidation. Negative views in the form of being forced by the institute prevailed among a few of them.
The new interns are the heroes for their ever-loving parents, the culmination of 4½ years of hard work. Parents felt the impact of COVID-19 disease with the news of their wards being posted to the areas where the virus was circulating. Objections were raised by many parents (41.7%) as they were afraid too, especially concerned for the safety of the female interns, who were a majority. Health-care workers putting their health and most importantly live at risk was evident in most countries.,,, Hence, naturally, this kind of reaction was expected from the parents, but almost a quarter of the interns reported that their parents (25.3%) encouraged and motivated them to fight the pandemic.
As the medical interns from a private medical college were working in the government setup for the first time, they were dissatisfied with the food (46%) and accommodation (45%) provided. It was a hot summer that added to their woes. The dissatisfaction could be due to their high expectations, which were not met, for example, air-conditioning in the rooms. However, most of them were happy with the transportation provided to them (70%). This situation exposed them to understand the ground realities of fieldwork and coping mechanisms. Many interns quickly adapted to these conditions and were satisfied while some could not cope up and were left dissatisfied.
The COVID warriors depend on PPE to protect themselves and their contacts from being infected and infecting others., Many interns (70%) were quite dissatisfied with the PPEs provided. Initially, they were provided with cloth masks, and later on, they rated low quality with surgical masks. However, a few municipalities provided the interns with gloves and sanitizers. Interns who worked at Srikalahasti reported that they were provided with PPE when the surveillance duty was almost ending; thus, they were unprotected most of the time. The interns were expecting the PPE as per the guidelines and did not gauge the system's unpreparedness. This could have been due to the acute shortage of PPE, which many countries experienced, leaving the system and workers ill-equipped worldwide.,,,
The interns started their duties with grassroot level staff (accredited social health activists, auxiliary nurse midwives [ANMs], and voluntary health workers), so most of them felt that the staff were very cooperative and helpful. That is when they realized the staff's myriad job responsibilities and how they operated in the field. The interns opined that early detection of cases was possible because of the efforts put in by the grass-root level staff members. However, the interns felt bad as these staff members were not provided with better facilities (food, transportation, and PPE). They were also skeptical and afraid of working with them as the teams worked without much protection. This observation exposes the gaps in India's public health system where the frontline workers are not provided basic facilities. The Indian government's expenditure on health barely touches 1.5% of GDP, and persistent underinvesting on the public health system has made the task of containing this pandemic even more difficult.
Directly working with the public as doctors was also a first experience for the interns. They felt that the communities they had been allotted were exceptionally welcoming and shared the information wholeheartedly. Nevertheless, as they went in for follow-ups, there were uncomfortable situations, which felt as if the public started rejecting them because of the fear that they might carry the infection. It also points to survey fatigue in the community, which is another problem. The number of interns reporting that people got irritated with successive visits almost doubled, as shown in [Figure 4]. This reminds us of the various instances of health-care workers facing discrimination during this pandemic. This can lead to many psychosocial problems such as insomnia, anxiety, depression, somatization, and obsessive–compulsive symptoms., Although the Government of India introduced a law for protecting health-care workers against violence during the pandemic, not much has been said about the health-care workers' mental health status. The concern about mental well-being was brought into the light because just 58.2% of the interns were passionately involved in their duties throughout the surveillance period. Only 65.6% of them felt satisfied at the end of their responsibilities. This should also raise concerns about the health-care staff's burnout due to continued efforts in fighting against the pandemic, the implications of this burnout on their performance, and the fight against the pandemic.
About 25.3% of the interns felt dejected after the news of their postings getting extended. A study by Damery et al. also suggested that 25% of doctors did not consider that it was essential to work while doing so would pose risks to themselves or their families., Reasons quoted for the interns dejection were that no proper PPE was provided. They felt the work they were doing was insignificant and could have done by grassroot level staff members. Only a few items of clean clothing were left with them, and that laundry was difficult. As always, exceptions exist, and in this case, a few (13.4%) were excited to carry their work forward as they felt this was the right opportunity for them to serve people, especially in the thick of the pandemic [Table 1].
A positive change was noted in their perception toward the medical profession, as reported by 71.6% of interns. This was the best outcome of the community surveillance posting, according to them. They said that they learned many things about the public health-care system through the experience of working with the grassroot level workers and were happy to socialize with ANMs, volunteers, the public, and their colleagues. Therefore, beginning a career during the pandemic will make them mentally strong to face the challenges and become better professionals.
While it is eye-opening to learn the interns' perspectives and experiences in the field, the possibility of recall bias, social desirability bias, and interviewer variability are some evident limitations. Maybe a multicentric study with interns from other districts conducted concurrently during the surveillance activity or immediately after would generate better in-depth data.
| Conclusions|| |
The COVID-19 pandemic has exposed the naive medical interns to the harsh realities and challenges of the health professionals, frontline health workers, and the health system. This experience has given them the confidence they would require for starting their careers as doctors and future health workforce. Capturing these young doctors' experience has helped us recognize their acumen and adaptability; it also provided us with the inputs to understand the surveillance process, its strengths, lacunae, and challenges the system faces through a fresh set of eyes.
A SWOT analysis of this surveillance process based on the interns' experience has highlighted vital insights to help the stakeholders decide the right course of action to prepare for future public health emergencies. Most importantly, developing a framework for the health care staff's training, especially the medical interns and providing proper equipment/PPE facilitates surveillance activity and handling future challenges.
Utilization of digital technologies and geo-tagging various high-risk communities/households could be tried in subsequent surveillance to make the process robust and efficient.,,
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (STROBE for quantitative and S.R.Q.R. for qualitative components). The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is PESIMSR/IHEC/203 dated June 30, 2020.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]