Concerns, Positive Changes, and Suggestions for Psychological Support during COVID-19: A Thematic Analysis

Background: On 12 March 2020, Slovenia formally declared the presence of a pandemic of COVID-19 disease, followed by measures to stop the spread of the virus. Scope: The aim of this study was to explore how people experienced the progress of events related to the COVID-19 epidemic. Method: We conducted a general adult population survey by an online questionnaire that included—among others—three open-ended questions. Thematic analysis was applied for each question separately to identify key patterns in the data. Results: The first topic (questions about the epidemic) resulted in four core themes: concerns about the disease, concerns about the future, concerns about measures, and concerns about well-being and daily life. The second topic (positive changes during the epidemic) resulted in three core themes: changes in oneself, changes in close relationships, and changes in the environment and society. Lastly, the third topic (requests for psychological support during the epidemic) resulted in three core themes: direct help and support, information and awareness raising, and media activity. Conclusion: Overall, the themes that emerged from our study provide information that can help in understanding how people perceive the influence on their mental health and well-being of the negative and (some) positive effects of the COVID-19 epidemic. This may be helpful in the general preparedness to a feared second wave of the pandemic.


Introduction
On 30 January 2020, the World Health Organization (WHO) declared the emergence of the novel coronavirus as a public health emergency of international concern. On 11 February 2020, the infection deriving from this novel coronavirus was officially named as Corona Virus Disease 2019 (COVID-19), and, on 11 March 2020, WHO conceded the status of pandemic to it (WHO, 2020). On 12 March 2020, Slovenia declared an epidemic of COVID-19, followed by measures to stop the spread of the virus (Government of the Republic of Slovenia, 2020a).
The start of the epidemic was marked by anxiety-related behaviors in the general population, such as extensive shopping for food, and shortage of masks and antiseptics in drug stores. Slovenia is a neighboring country of Italy, which has been one of the countries worst hit by COVID-19, with around 80% of cases registered in the north of the country (Michelozzi et al., 2020), which is the border of Slovenia. Nonetheless, the spread of the coronavirus was quickly slowing down in Slovenia, so the government could cancel the formal status of epidemic on 15 May. By that date, there were 1465 positive cases formally detected, and 103 deaths related to the virus (Government of the Republic of Slovenia, 2020b).
However, despite the official end of the epidemic danger, the risk of spread still exists, so protective measures continue to be in place.
Considering that these measures affect individuals' daily lives, they may also affect their well-being (Sani et al., 2020). For example, in a review about psychological impact of quarantine, Brooks et al. (2020) reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger.
The SARS-CoV-2 (responsible for the pandemic of COVID-19) triggered the biggest economic meltdown in a century, with stock prices dropping in various parts of the world (Shigemura et al., 2020). The results of a survey done by Eurofound (2020) show that almost 40% of people in Europe reported their financial situation to be worse than before the pandemic. This leads to fears of economic hardship, stress and feelings of helplessness and hopelessness (Polizzi et al., 2020;Park et al., 2020). Sritharan & Sritharan (2020) emphasize that the COVID-19 pandemic is expected to continue for the coming months, with the possibility of multiple waves.
Given that it is already evident that the psychological effects of the pandemic are pervasive and could affect mental health of people (Holmes et al., 2020), it is imperative to understand the magnitude of mental health issues that may arise during and after this public health crisis.  (Nelson, 2020;Szabo et al., 2020) have also noticed some positive effects of the coronavirus pandemic, such as innovative communication (Karampampas, 2020;Kraus et al., 2020) and feelings of improved social connectedness (Johnson et al., 2020). Positive emotions and good mood have important roles in coping processes to distressing situations (Folkman, 2008;Erikson & Feldstein, 2007;Restubog et al., 2020). Nevertheless, these have been relatively neglected in research studying stress coping strategies during outbreaks (Yıldırım et al., 2020).
In response to the new coronavirus outbreak, implementation of psychological support for health workers has been developed and promoted (Geoffroy et al., 2020;Leszcz et al., 2020;Cole et al., 2020). However, research shows (Makwana, 2019) that in times of crisis, everyone, not just health workers, is more likely to develop mental health problems. For this reason, it is important to develop guidelines on how to implement psychological support for the general public.
For example, research on chronic patients (Ciacci & Siniscalchi, 2020) has shown that new technologies can help to support patients who are in need of psychological support. These findings may be transferable to general public.
While an emerging body of research has shown negative effects of the COVID-19 pandemic on people's well-being, research into the overall perception of the events surrounding the pandemic has been largely neglected. It is crucial to understand how people perceive both the negative and positive consequences of the COVID-19 pandemic in order to increase the level of preparedness in the case of a second or multiple waves of the virus. It is also important to provide people with appropriate psychological support in times of crisis, such as a pandemic.
The aim of this study was to explore how individuals experienced the progress of events concerning the epidemic, focusing on their concerns, possible positive changes and wishes for psychological support during the epidemic.

Participants
Participants to the survey were 207 adult people, aged between 19 to 75 years old (M = 32.96, SD = 11.38); of those, 175 (84.5%) were women. Detailed sample characteristics can be seen in Table 1.

Measures
We conducted a survey through an online questionnaire. Our study was conducted during the peak of the epidemic in Slovenia, when all containment measures were in force (social distancing, lockdown of municipalities, closure of kindergartens and schools, closure of public transport, etc.). The questionnaire included items about demographic variables (gender, age, education, personal

Procedure
This study obtained data from research "Exploring the link between the COVID-

epidemic and mental health aspects (adults) under the research programme
Alive? Alive!" conducted in Slovenia between 26 March and 7 April 2020. The Research Ethics Commission of the UP Famnit Department of Psychology judged that the research complied with the principles of research ethics (application number 2020-05).
Online recruitment was realised through social media (Facebook) and through the website of an ongoing project of the Slovene Centre for Suicide Research (http://zivziv.si/). Initially, descriptive analyses were performed to examine sample characteristics, using SPSS version 26. This was followed by thematic analysis, that was applied for each question separately, using the six-phase framework to identify key patterns in the data (Braun & Clarke, 2006;Clarke & Braun, 2017): 1) familiarizing with the data; 2) generating initial codes; 3) searching for themes; 4) reviewing of the themes; 5) defining and naming of themes; and, 6) reporting the findings.

Results
The thematic analysis was conducted separately for each question, so that we

Concerns about the Epidemic
The first topic (participants' concerns about the epidemic) led to four core themes: concerns about the disease, concerns about the future, concerns about the measures, and concerns about well-being and daily life.
Example of a quote from the first topic: "I am most concerned about my own health because I belong to the risk group. Then I worry about the health of my parents, who also belong to the risk group. I am also worried about the situation we will find ourselves in when the health crisis is solved and our world is economically ruined and needs to be rebuilt".

Theme 1: Concerns about the Disease
The participants reported fears of being infected or becoming infected and not knowing about it due to lack of symptoms. As a result, they were afraid of infecting their loved ones and others. They were also afraid of the disease itself, especially the consequences of the disease for their long-term well-being and health. They worried about who would take care of their children if they became ill. Dying because of COVID-19 was also a reported concern.
Participants reported concerns that family members and loved ones would fall ill, especially older relatives (who belonged to the group at risk). Participants feared that their elderly or chronically-ill close relatives would die if infected.
They also reported fears of a massive spread of infection due to failure of protective measures, which would lead to overburdening the health care system. Consequently, they feared that such a situation would lead to mass deaths. Finally, they reported concern about the spread of panic among people.

Theme 2: Concerns about the Future
With regards to the future, participants reported mainly on the unpredictability of it-they were worried about what the future would look like, what the new normality would look like. They feared unpredictable social and political consequences, but also possible changes to the environment.
Another concern was the duration of the epidemic; they feared that the long duration of the epidemic and the emergency measures would lead to serious consequences for their way of living. They expressed concern about when they would be able to return to normal life, and when they could see their loved ones and socialize as before.

Theme 3: Concerns about the Measures
Participants reported concerns about the impact of measures on jobs and the economy. They feared an imminent financial and economic crisis. As a result, they feared losing their job or not being able to find work and, thus, losing the possibility of a regular income. With regard to the measures taken by the government, participants expressed concern that politicians were exploiting the epidemiological situation by violating human rights. Some measures were per-

Concerns about Well-Being and Daily Life
Participants reported concerns about own well-being and mental health and that of other people. They also expressed some concerns about pregnancy or childbirth at the time of the epidemic, and concerns about homeschooling of children as well as traveling to other countries.

Positive Changes during the Epidemic
With regards to perceiving possible positive changes in time of COVID-19, this resulted in three core themes: 1) changes in oneself; 2) changes in close relationships; and, 3) changes in the environment and society.
Example of a quote from the second topic: "It seems to me that many people have become more relaxed in the sense that time no longer weights so heavily on them. Many have contact with their families and finally have time for each other. When I walk down the street, I notice that people are looking for eye contact and greetings, because it looks like we are really all in the same boat and feel empathy for each other. A lot of goodness has awakened in people. I notice that many people still choose to volunteer and help wherever they can. In all this chaos, many beautiful things are happening, even the planet is finally breathing a little easier, at least for a while".

Theme 1: Changes in Oneself
Participants reported getting to know themselves better, learn about priorities, values, their inner strength and happiness, the importance of loved ones in their lives and about their life experiences. They felt more grateful and less focused on materialism and consumerism.
They also reported that they found more time for themselves, which they used for regular physical exercise, new sports activities, more time in natural environments, creative activities and eating healthy food. They also reported that they were trying out various new hobbies for which they had not had time before, such as relaxation, mindfulness and yoga techniques.
They experienced a greater sense of calm, a life in the "here and now", less daily rush, less or no time to commute and fewer daily commitments. As a result, they felt more motivated for activities that they would otherwise postpone; they were more concentrated, organized and less tired at work.

Theme 2: Changes in Close Relationships
Participants reported that they felt more connected to others, that they established better relationships and also felt more empathy towards other people.
There was more time for the loved ones, and the quality of time spent with the family was better. They communicated more, even if only by phone or online Sociology Mind media. Keeping in good spirit was a way to connect with loved ones and at the same time a mechanism for coping with the epidemic.

Theme 3: Changes in the Environment and Society
Participants noticed less polluted air and less pollution in general, a cleaner environment and less traffic. They also noticed that, in general, people followed safety instructions, which they perceived as a major concern for society. There was a feeling of mutual solidarity, friendliness for each other and good "team" spirit: e.g. balcony concerts. Solidarity was also shown in volunteer work, e.g.
helping elderly people with shopping. Society was changing due to the epidemic, and these changes included more local shopping initiatives and the development of home delivery, which was perceived as positive.

Wishes for Psychological Support during the Epidemic
The third topic, participants' wishes for psychological support during the COVID-19, yielded three core themes: 1) direct help and support; 2) information and awareness raising; and, 3) media activity.
Example of a quote from the third topic: "I would like reassuring information, instructions on how to take care of mental health and the possibility of direct help (online, telephone) for those who need it".

Theme 1: Direct Help and Support
Participants expressed their wishes for counseling and psychological support via telephone or video therapy. They stressed that help should be accessible and free of charge. Particular attention should be paid to older adults, sick and vulnerable people, people with mental health problems, pregnant women, people without Internet access, and victims of domestic violence.
They also wanted guidance on motivational, relaxation and coping techniques, as well as on learning mindfulness and meditation.

Theme 2: Information and Awareness Raising
Participants would like to receive educational and informational content in the form of concrete information and ideas or suggestions for mental health exercises and activities. Tips for dealing with isolation, fear, stress and feelings of helplessness would also be helpful. They would also like some practical tips on how to best co-habiting, how to maintain mental health and how to stay calm in certain situations, e.g. when shopping.
Participants expressed the need for information on the impact of the epidemic on mental health. They suggested raising awareness through webinars or online lectures.

Theme 3: Media Activity
With regard to the media activities of psychologists, participants wrote about increasing information on mental health issues and helping journalists to create appropriate content. In addition, they wished that the experts would help to

Discussion
The aim of this study was to investigate participants' concerns, We also examined possible perception of positive changes by the participants.
Their reports are consistent with previous research on better and more innovative communication (Karampampas, 2020;Kraus et al., 2020) and feelings of social connection (Johnson et al., 2020). They also reported on the importance of humor as a way to connect with loved ones and as a mechanism for coping with an epidemic, which is consistent with previous research (Folkman, 2008;Erikson & Feldstein, 2007;Restubog et al., 2020 also expressed the importance of media activity, which should be more informative, reassuring and positive. This reflects the concern expressed about the unpredictability of the future and the fear of an economic crisis. Our findings suggest that psychologists should be more involved in media coverage, as this would provide an opportunity to reach a wider public and offer them educational, helpful and reassuring information on the mental health aspect of the COVID-19 epidemic.

Conclusion
Strengths of this study were that participants were detailed in their responses and shared a large amount of information. The anonymity of the process enabled this level of disclosure. This study also broadened the participant pool by accessing participants from a range of ages. However, there were limitations to the study. The sampling strategy was not random and this may therefore lead to bias, as it was impossible for people without access to the Internet to participate in the study. Second, most individuals of our sample were females and younger people, and therefore findings may not transfer to males and older people. The study is based on a qualitative analysis of the participants' subjective experiences. Therefore, one of the limitations is that the results of the study cannot be generalized due to the chosen method, the purpose of which was to understand and explain the data. Future studies will use methods allowing for data generalization and sample representativeness.
Overall, themes emerging in our study provided information that can be helpful in understanding how people perceive negative and eventually positive effects of the COVID-19 epidemic on mental health and well-being. In addition, results provided suggestions on how to organise psychological support that can be used to design and implement mental health interventions to ensure people's well-being during and after epidemics. It would be possible to prevent or mitigate their worries (e.g. by reducing fears of unpredictable future scenarios through reassurance and consistency of information), reinforce perceived positive changes (e.g. enhancing the sense of calm through the use of mindfulness and relaxation techniques), and, most importantly, address people's needs and wishes for psychological support. All these measures could be important strategies in increasing the level of preparedness in the feared case of a second or multiple waves of the virus.