Participants and recruitment

Seven medical doctors from four districts in Lesotho participated in the research (see Table 1). Mean age was 36 (range 31–48) and mean number of years as a doctor was 7 (rounded to the nearest year; range 2–15). All but one of the doctors were Basotho (from Lesotho); the non-Basotho doctor came from another sub-Saharan African country. All doctors were working in government facilities in Lesotho before, during and after the COVID-19 pandemic. Participants were recruited using purposive sampling; qualified doctors working in Lesotho during the COVID-19 pandemic with an ability to speak English to a standard enabling them to participate in the interview and without any major mental health concerns were eligible to participate. With the support of two charities working across Lesotho and Wales, senior medical professionals in one hospital, one clinic and Lesotho’s family medicine training programme were approached to seek their support in recruiting participants. Initial emails introducing the research aim and methods were followed up with face-to-face meetings led by the first author to provide further information. These senior professionals then identified staff who were eligible for recruitment. Between the 11^th and 18^th of November 2022, face-to-face meetings with these individuals were arranged to discuss their participation; they were provided with verbal and written information about the research (aim, methods, data use, right to withdraw, benefits and possible risks) and invited to ask any questions prior to participation. Seven doctors chose to participate, and interviews either took place immediately or a later time, depending on the participant’s preference.

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Table 1. Participant demographics.

https://doi.org/10.1371/journal.pone.0350935.t001

Procedure

This study took a qualitative design. Interpretative Phenomenological Analysis (IPA) [17] was utilised due to its focus on subjective phenomena and the lived experience of participants. The intercultural nature of this research meant IPA would be particularly advantageous in supporting cultural humility due to its social constructionist stance. Its use of the double hermeneutic encourages researchers to discover and examine their own assumptions and interpretations [18]. IPA explicitly acknowledges the role of the researcher within the interpretation of the data allowing for recognition that the differing cultures of researchers and participants will have an impact on the results.

A semi-structured interview guide was created and reviewed by the research team. The initial protocol and versions of the interview guide focused on exploring stress, but this was replaced with the word ‘wellbeing’ to allow for a broader and less researcher-led exploration of doctors’ experiences. The guide was developed and structured to allow for participants to settle into the interview and think about changes to the job as a result of COVID-19. It then explored topics relating to the research question, including what the word “wellbeing” meant to participants and any positive or negative impacts COVID-19 had on their wellbeing. Interviews were conducted by the first author, in Lesotho, at participants’ places of work. Due to the potentially distressing nature of the interview topics, it was planned for the first author (a trainee Clinical Psychologist) to utilise her clinical skills to support interviewees experiencing distress in the first instance. Senior medical professionals in the different districts were consulted as to where interviewees could be signposted to should they require further support; approaching mental health staff within the local hospitals was advised as the only option available.

Semi-structured interviews were conducted on a one-to-one basis in a private room at a location convenient to the participant. As per IPA tradition, the interview guide was used flexibly, with participants encouraged to explore aspects of experience that they felt were interesting or important. At the end of the interview, basic demographic data and information regarding the participant’s wish to review the results and/or final article prior to the report being submitted was collected. The mean duration of the interviews was 73 minutes (range 44–92). Interviews were conducted in English, audio-recorded and transcribed verbatim (with significant non-verbal communication such as laughter and long pauses) by the first author.

During the study preparation, interview and data analysis stages, a reflective log was kept by the first author to support bracketing of assumptions and ownership of one’s own perspective. The fourth author, a Lesotho-based researcher and medical doctor, acted as a cultural consultant during the study, particularly in relation to the cultural appropriateness of the interview guide, interview procedure and data analysis.

Ethical considerations

Ethical approval was granted by the School of Human and Behavioural Sciences ethics committee at Bangor University, Wales, UK (Ref: 2022–17164) and by the Ministry of Health’s Research Ethics Committee, Lesotho (Ref: ID 190–2022). Verbal consent to undertake this research within specific medical facilities was provided by senior medical professionals within those facilities. Participants provided written consent to participate in the research, and were reminded of their right to withdraw and confidentiality prior to interviews commencing.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information S1 Checklist.

Data analysis

Utilising processes illustrated by Smith, Flowers and Larkin [18], each transcript was examined for its descriptive, conceptual and linguistic features pertaining to the study’s aims. These initial exploratory notes alongside the transcript were transformed into experiential statements and then personal experiential themes (PETs). The cultural consultant then reviewed the exploratory notes, experiential statements and PETs providing feedback on the analysis’ cultural appropriateness. Each transcript was analysed as an individual piece with the first author bracketing off outcomes from previous transcripts. Finally, the PETs were analysed to form group experiential themes (GETs). As suggested by Smith, Flowers and Larkin [18] a GET was only included if it consisted of data from at least four participants.

Four of the seven participants had opted to review the results for accuracy and cultural appropriateness before the report was finalised. The results were emailed to them, however no participants responded, and it was assumed there were no concerns regarding the results.

Epistemological approach

A constructivist stance was adopted during this research, which assumes that knowledge is developed within a person’s own context through interactions with the world. This has close links with hermeneutic phenomenology which is the basis for IPA and aims to understand a person’s lived experience in a particular context through their interpretations of these experiences. This is appropriate for intercultural research whereby individuals’ experiences are seen to shape their understanding and interpretation of subsequent experiences. This was important for this research as it was desirable to avoid imposing Western constructs onto the participants. Through taking a constructivist approach, the authors were able to question and consider various elements of the research process and their acceptability for the participants. For example, the construct of ‘wellbeing’ was not assumed to have the same qualities across cultures and between individuals, therefore part of the interview involved exploring with participants what their meaning of the word ‘wellbeing’ was.

Reflexive statement

The first author, a female, white British, trainee Clinical Psychologist with a Psychology BSc, conducted the interviews and data analysis. Concerns regarding being a cultural and racial outsider, and power imbalances in relation to this, were managed through discussions with the cultural consultant, other professionals who had worked in Lesotho, and spending time in Lesotho familiarising herself with the culture and healthcare system. Her previous work in Sub-Saharan Africa created assumptions about the nature of the results. These included an expectation that familial and community relationships would be seen as key to coping during the pandemic, that any mental health problems would be minimised due to fear of stigmatisation, and that staff would be experiencing stress due to a difficult work environment. As per the IPA approach, these assumptions were reflected upon and bracketed off prior to conducting the interviews and analysis [18].

Analysis was led by the data; however, the first author’s individualistic cultural background and mental health training are likely to have influenced the results. Whilst this is acknowledged as an inevitable part in the IPA process, the use of reflexivity, bracketing, and consultation with the cultural consultant were vital in minimising the impact. To counteract the first author’s predisposition to focusing on psychological phenomena, she made a conscious effort during interviews to ask follow-up questions about other phenomena when they naturally arose, and during analysis to consciously avoid dismissing non-psychological phenomena (for example, the physical impact of stress).

Under pressure, unprepared and out of control

Constant uncertainty and threat

Participants’ wellbeing was impacted by the uncertainty and threat from COVID-19 which were experienced as constant, inescapable, and ‘terrifying’ (Participant 7). The uncertainty surrounding COVID-19 made the threat of death even more powerful, causing ‘dread’ (Participant 2) and ‘fear’ (Participant 6), and penetrating across time. ‘The stress was like, you don’t know what’s going to happen to you the next day. The future, you don’t know the future, what’s going to happen in future about yourself, about your family. That was eh the stress’ (Participant 3). Participant 7 felt similarly:

After the pandemic hit, it was a scary time… Um, I mean in that time we really should dance with death a lot, right… I feel like we met face-to face often times and so the reality of it really was more heightened. (Participant 7)

Participant 7’s fear of being ‘face-to-face’ with death; seeing healthy, young people die made the risk of death feel even more uncertain and that it could happen to anyone. ‘With COVID, it had no respect for health or ill health, age, you know, everyone was just game’ (Participant 7). The use of ‘dance with death’ and ‘face-to-face’ highlights the closeness that she experienced with death during this time; she was confronted with it, trying to make the right moves to delay the inevitable.

Isolation and connection

Attempts to cope independently

Whilst they were abandoned by authorities, and experienced isolation and aloneness, participants were able to turn towards themselves for support. Some doctors turned to religion, others to managing their physical health and some to emotion management strategies. Participant 5 described a journey of exploration in coping independently, sometimes reaching out for ways to cope which were ultimately not successful:

Sometimes you find yourself locking yourself in this office, you cry, you go home, you’re only thinking can I get something that can sedate me, you start [pause] drinking, unnecessarily, just to numb yourself, just for something that will make you not to think about this environment that you’re working in… I found myself doing things that I never had anticipated that I would do, just because I’m trying to relieve myself of the stress. (Participant 5)

This extract shows Participant 5’s attempts to distract herself from the difficulties and emotions. Desperation is felt in her attempts to do anything to cope, reaching out to things she never thought she would. However, some doctors described more success in self-care:

Something that I do not have control over [the death of a patient], yes I may feel that guilt, but… it’s a feeling and feeling is not um, the reality of what is going on, but now I had to understand that… and separate the feeling from the realities, yes, of life. (Participant 4)

Here Participant 4 describes balancing his emotions with rational thinking. Recognising that emotions are not necessarily a reflection of reality helped him to maintain his wellbeing.

Overall, relying on oneself during the pandemic was a key part of managing wellbeing, however the methods used varied between participants with varying degrees of success.

New perspectives

Despite the themes above, participants also spoke about the learning gained from working as a doctor during the pandemic. This impacted both their professional and personal lives. This view of the pandemic, as a time of learning and development, could be seen to mitigate the negative impact on wellbeing, as all the distress and loss were not for nothing.

Implications

Whilst the current study was not designed to be generalised, research across Africa has found similar results in relation to healthcare staff’s wellbeing being negatively impacted during the pandemic [41–43]. The current research suggests that those leading Lesotho’s healthcare system should provide more wellbeing support to staff, particularly in relation to how leaders and the government communicate with, value, and protect healthcare staff. This study also advocates for the provision of mental wellbeing resources for healthcare staff.

As the COVID-19 pandemic has eased, it is important that research continues to investigate the wellbeing of doctors in Lesotho to gain a better understanding of any long-term implications of the COVID-19 pandemic and doctors’ wellbeing during more typical work. Gender differences were not explored within this research, and given the persistent gender inequality within Lesotho and across the world, this is an important area of investigation to better understand the impact of gender inequality on doctors’ experiences.

Limitations

All interviews were conducted in English, one of the official languages of Lesotho, but less frequently used than Sesotho. Whilst all doctors were able to communicate in English to a high level and some would have trained in an English-speaking context, this may still have limited their ability to fully express themselves. The interviews may have elicited even richer data had they been conducted in Sesotho. However, translation comes with its own limitations; finding appropriate translations for metaphors or words without a direct translation, and the translator’s decisions on how to translate words, are just two examples of how translation can alter the meaning of a person’s words [44,45]. Furthermore, the use of English may have magnified any power differences between the interviewer and participants. Whilst this research aimed to be culturally sensitive, the use of English can be seen as a version of colonialism within research.

Similarly, the majority of psychological models, concepts, and narratives have been developed in Western contexts. Whilst efforts were made to analyse and interpret the data in a culturally sensitive manner, it cannot be ignored that Western narratives dominate, and it is impossible as a researcher from a Western population to completely detach oneself from these narratives. The use of IPA helped to keep this in mind and acknowledge that the first author has given a different perspective to the data than may have been achieved with a Basotho researcher. The inclusion of the cultural consultant helped develop cultural appropriateness during data analysis.