Background

The COVID-19 pandemic has disrupted many facets of life, resulting in social and economic distress on unprecedented levels. Social distancing, isolation, and country-wide lockdown measures aimed at reducing virus transmission have created stressful experiences for families, particularly those who were already vulnerable [1]. Many ethnic minority groups have disproportionately experienced the negative effects of the COVID-19 pandemic compared to the wider British population [2] having been impacted by both the high virus transmission and socio-economic consequences [3]. These differences in outcomes have been attributed to factors such as working in front-line occupations; living in large, multigenerational households; prevalence of pre-existing health conditions; discrimination, and a lack of access to health or community services [4–6].

There is a plethora of evidence from the United Kingdom demonstrating that lockdown measures to control the spread of the COVID-19 virus have led to an increase in poor mental health [7–9]. There is also evidence that mental health inequalities have been compounded by the pandemic with the groups suffering from the poorest mental health pre-pandemic also having the largest deterioration [10]. Other factors that have been found to be associated with a deterioration in mental health are low socioeconomic status, loneliness, being an adult, a woman and being a parent to a young child [9–11]. Evidence of the impact of the pandemic on the mental health of ethnic minority groups has been unclear. Two recent studies that have included a large proportion of ethnic minority mothers from Pakistani, Bangladeshi, and White other backgrounds have reported no differences in the likelihood of experiencing mental ill health during the pandemic once other key risk factors have been controlled for [11, 12]. These studies instead showed that the key risks associated with increased mental ill health during the pandemic were financial and food insecurity, loneliness, low levels of physical activity and a poor partner relationship. There was also a greater prevalence of depression in those families living in areas of London compared to Bradford.

One of these studies (Dickerson et al. 2022) looked at the likelihood of experiencing depression during, compared to before, the pandemic and reported differences in the magnitude of the risks associated with becoming depressed by ethnicity: Pakistani heritage mothers were more likely to experience depression if they were lonely or had a poor partner relationship, but were far less likely to experience depression if they lived in a large household; whereas White British women were more likely to experience depression if they were financially insecure or had low levels of physical activity [11]. The authors noted that more exploratory research in this area would enable accurate understanding of the possible differing experiences and needs of this population.

Stress factors for Pakistani women have been reported to stem from their South Asian cultural background including their cultural, gender role as women in the family and cultural conflict concerning izzat (i.e., honour/respect), social isolation and migration related stress [13–15]. There may also be some protective factors at play in this community such as living in a close-knit community and multi-generational households that may protect against risk factors such as loneliness and financial insecurity. It is important to note, however, that both aforementioned studies [11, 12] used mainly quantitative approaches and were therefore unable to explore in detail, some of the experiences of British Pakistani women during the pandemic to gain a richer understanding of the factors that may have contributed to their mental wellbeing. This study, therefore, uses qualitative interviews to understand in-depth the mental health experiences, including risk and protective factors of British Muslim Pakistani women with family responsibilities throughout the pandemic in Bradford, UK. This location was selected due to the exceptionally high rates of virus transmission and mortality from COVID-19 in the region. As a consequence of these high rates, there were tighter regional restrictions in Bradford, as well as in the more deprived cities of Northern England through 2020–2021 [11]. As previously mentioned, being a woman, and a parent to a young child, was evidenced to exacerbate poor mental health during the pandemic. As such, Pakistani women with family responsibilities more specifically, were selected due to their unique role in family dynamics and potential vulnerabilities during the pandemic.

Methods

Data collection

One-on-one interviews were deemed to be the most suitable data collection tool for the purpose of this study to enable detailed exploration of personal lived experiences [19] of participants during the pandemic. An interview guide was developed by HI and BL and included semi-structured, open-ended questions to facilitate discussions. Input was obtained from a researcher with experience of conducting interviews on the topic of mental health with Pakistani women. The guide was piloted on three British Muslim Pakistani women with family responsibilities living in Bradford, over the telephone and one in person and was refined based on their feedback. The data generated from the pilot interview is not included in this paper. The interview guide is displayed in Table 1. Participants were offered a £20 shopping voucher to thank them for taking part. Data were collected by HI through phone calls from April-May 2022 as per participants’ requests, at a time that suited them. For non-English speaking interviews, the interview questions were translated into Urdu while staying as close to their English meaning as possible to limit bias. Interview length averaged 55 minutes. Data collection continued until saturation i.e., no new insights emerged from the data [20]. Data saturation was reached by interview 25.

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Table 1. Interview guide.

https://doi.org/10.1371/journal.pone.0292614.t001

Results

A total of 25 British Muslim Pakistani women with family responsibilities took part in the study. Twenty were English speaking and five spoke Urdu only. The number of people living within households ranged from 3 to 14. To protect participants identities, a range has been given rather than specific numbers of people per household. Participants lived in neighbourhoods with varying levels of deprivation. Table 2 displays participant characteristics. Pseudonyms are given to protect participant identities. A tick in the column means yes and an X in the column means no

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Table 2. Participant characteristics.

https://doi.org/10.1371/journal.pone.0292614.t002

There were three themes identified in the data that demonstrated the impact of the COVID-19 pandemic on the lives of British Muslim Pakistani women with family responsibilities. The themes were (1) Community, cultural and religious contributors to poor mental wellbeing, (2) religious and cultural mediators of psychological distress, and (3), positive impacts on lifestyle. The themes and codes are displayed in Table 3 and are presented below with illustrative quotes. Quotes have been pseudonymised for purposes of anonymity.

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Table 3. Themes and codes.

https://doi.org/10.1371/journal.pone.0292614.t003

Discussion

The findings from this qualitative study exploring the mental wellbeing of British Muslim Pakistani women with family responsibilities during the COVID-19 pandemic found that mental health was particularly affected by the prospect of extended family living in the same house contracting the virus, as well as concern for relatives living abroad. Anxieties were exacerbated by the high virus transmission and deaths in the South Asian population. The lack of religious interaction during Ramadan and the inability to attend funeral rituals and participate in cultural traditions were an additional source of worry. Religious beliefs served as protective factors against poor mental wellbeing in Pakistani women, as well as support they received from their community networks and the family, particularly the support from family members which reduced household burdens and therefore allowed them respite. Positive outcomes of the pandemic were also highlighted such as spending more time with family, becoming more religiously observant and welcoming the slower pace of life.

Our findings show that Pakistani women were very concerned about family members contracting the virus. Although this has been identified as a worry among the general population in the wider literature [11, 23, 24], it was especially notable among Pakistani women in this study because many of them lived with extended, older family which included their mothers, aunts, and in-laws. Intergenerational living with larger household sizes are common among South Asians [25]. Research has shown that in individuals presenting with suspected COVID-19, those from ethnic minority communities and larger households had an increased likelihood of testing positive for the virus [26]. People from ethnic minority communities, therefore, may have intense fears and anxieties in relation to the increased risk of COVID-19 in their communities [27]. Like our study, other studies have also revealed a mental health impact from the lockdown on minority ethnic women with family responsibilities, with increased domestic load being cited as a reason for increased anxiety in these populations due to large household sizes [28]. Our study found that the lack of Pakistani husbands’ support with household chores exacerbated their stress levels. Our study, however, also found that extended family members living in the same household alleviated the tension by offering domestic support during lockdowns. It is important to note, however, that it was primarily female family members that provided domestic support, such as daughters and aunts. Often, the negative aspects of living in large households have been focused on but as our study shows, living in large households resulted in both positive and negative outcomes for women.

Physical distancing from social networks have been some of the most challenging lifestyle changes made by individuals during the COVID-19 pandemic [29]. Like other studies, we found that restrictions on interactions with others caused considerable distress [30]. For the Muslim community, however, there were specific consequences of restrictions on cultural and religious practices [24]. Practices such as coming together as a community to break the fast during Ramadan, and not being able to visit family for the Eid celebration, caused much distress to this population. A further example can be seen in funeral practices in this population. There are ethnic, cultural and religious differences in funeral practices [31] which were affected to varying degrees by the COVID-19 restrictions during the lockdowns. The ritual act of washing the body of the diseased, for example–a crucial act in Islam–was, at the time, being carried out wearing full personal protective equipment with supervision or not at all [32]. A ritualistic three days of Islamic mourning is observed by Muslims, wherein the community and family provide support to one another [33]. This religious mourning process was disrupted by COVID-19. As seen in this study, the impact of restrictions on funeral practices in the Pakistani Muslim community are a source of communal as well as individual distress. These cultural and religious practices are integral to the sense of belonging and connectedness within the Muslim community and the impact of restrictions on these practices have had continued effects even after restrictions were lifted. Evidence from our study and those of others recommend the need for further research to develop in-depth understanding of the role of culture and religion in populations’ coping during pandemics and the importance of considering culture and religion when developing COVID-19 guidance [24, 34].

Participants spoke of coping strategies to mitigate the psychological impact of the pandemic on their wellbeing. A range of coping strategies during the COVID-19 pandemic have been identified in the wider literature, which include engaging in hobbies and activities and staying connected with others [23]. In this study, however, women spoke extensively of religious coping mechanisms. For many people from minority ethnic backgrounds, religion can provide social support, a sense of meaning and connection, and more importantly, exposure to social norms linked with the group membership [35]. In our study, religion and spirituality enabled British Muslim Pakistani women with family responsibilities to cope and thus offered respite from the psychological distress associated with the COVID-19 pandemic. Central to this was the acceptance of the situation caused by the pandemic, expressions of gratitude and patience as propagated by prophets, and a belief in predestination. Positive religious coping is associated with improving physical and mental health outcomes, whereas negative religious coping has been linked with increased stress and anxiety [36]. Other studies have also found that positive religious coping provided individuals with a protective buffer against negative mental wellbeing in those reporting a strong religious identity during the COVID 19 pandemic [24, 37]. Positive religious coping, therefore, may help these populations reduce their risk of poor mental wellbeing, which could be of great benefit for Muslim communities more generally across the UK. An exploration of religious coping may prove beneficial in informing broader national pandemic preparedness plans in the future.

Our study found that support from neighbours served as a protective factor, especially among women who were born and raised in Pakistan and did not have extended family in England. Many of the women in our study reported residency in areas of high own group density. Areas of high ethnic density have been shown to buffer against the effects of severe mental illness in South Asians relative to White British populations with severe illness [38]. Community assets such as community cohesion and neighbourliness within a community can support health and wellbeing [39]. It has been previously reported that in deprived areas of Bradford, Pakistani women are more likely to report low family social capital compared to White British women [40]. Our findings indicate that neighbourhood relations might become more important in times of societal crisis and social restriction measures, when public support services may decrease, or support from the family is limited. Findings from this study indicate that neighbourhoods with high social capital seem to be more resilient to crisis like the COVID-19 pandemic [41]. This corresponds with findings from previous research, suggesting that a high level of social capital promotes health [42, 43], and may help to explain why women from Pakistani and Bangladeshi ethnic minority backgrounds had greater prevalence of depression in London than in Bradford. A more thorough understanding is needed of effective strategies for building and maintaining social capital during future crises as social capital may increase adherence to physical distancing and other protective behaviours in populations.

Throughout the COVID-19 pandemic, efforts were made to incorporate learning from previous epidemics in the development of wellbeing guidelines and support interventions, but many of these guidelines and interventions focused mainly on the assessment of clinical outcomes, which often excluded cultural descriptions of wellbeing and mental health [44]. In terms of coping with the damaging mental health effects of the COVID 19 pandemic, this study found that British Pakistani women relied on informal support from family and friends. Dong et al. (2022) found that addressing cultural factors and support mechanisms would improve mental health and wellbeing [45]. Also, some British Pakistani women stated that they used their own methods to cope, such as religion and spirituality. This supports growing evidence that religious coping improved wellbeing [46]. Enhancing mental health and wellbeing through spiritual and faith-based groups will equip British Pakistani women with resilience building tools, self-care and coping strategies, and empower them to seek support when needed. Our study provided insight into excessive responsibilities of British Pakistani women that prevented them from carrying out their roles as they would have liked, particularly in the case of their responsibilities towards loved ones. Research has found the fear and anxiety of passing on COVID-19 to family members is a persistent concern and for British Pakistani women, impacted their descriptions of wellbeing. This emphasised the need to include this in pandemic response guidelines. Furthermore, it appears that social support is an integral element of maintaining British Pakistani women’s mental health as previous studies have found that a lack of social support affects anxiety, and stress [47]. It is important to foster supportive networks in future pandemics, through encouraging peer support and sharing of experiences to mitigate the negative impact on mental health.

This study includes in-depth experiences of British Muslim Pakistani women, a community who are considered ‘seldom-heard’ and ‘under-researched’ and by including their perspectives in this research, we were able to understand both mental health risk and protective factors in this population that differed from other communities. We also included non-English speaking women whereas often, non-English speakers are excluded from research due to language barriers [48]. A key strength of this study is that the researcher (HI) held insider status as a British Muslim Pakistani mother living in Bradford. Research is often conducted by outsiders to communities without specific and local knowledge, which could result in, among other issues, participants’ mistrust of researchers, limited cultural insights by researchers, and lack of acceptance by the community [49, 50]. The insider position held by HI was important for facilitating discussion and enabled participants to express their experiences in ways and via language universally familiar within the both the Muslim and the Pakistani community.

It is possible that the insider status of HI could have resulted in bias, given her knowledge, and understanding of the community [51]. This issue was mitigated by HI being extra vigilant about her line of questioning and by allowing the interview to flow naturally with her limited input. Another limitation is that participants may have omitted details under the assumption that HI had insider knowledge. This issue was managed by HI asking participants for clarification when they were being vague. By focussing on British, Muslim, Pakistani women with family responsibilities living in the city of Bradford, some of the findings may be specific to that population. Future research would benefit from obtaining perspectives from a wider demographic. In addition, as data were not collected on whether participants were living with a diagnosed mental health condition, findings cannot be generalised to Pakistani Muslim women who have a history of mental health disorders as their experiences during the COVID-19 pandemic may have differed to the women in our study.

Conclusion

This study found that British Muslim Pakistani women with family responsibilities living in the UK were psychologically distressed by the high rates of virus transmission in their ethnic community and at the prospect of older members of their extended family, who lived with them, developing the virus. The impact of restrictions on fundamental religious and cultural interactions further exacerbated poor mental wellbeing in this population. Religion, community social capital and larger household structures were all protective factors for British Muslim Pakistani women with family responsibilities. An exploration of religious and cultural coping mechanisms should be used to inform future national pandemic preparedness plans, as well as effective strategies for building and maintaining social capital. This may increase adherence to physical distancing and other protective behaviours in populations. Attention should also be given to ways in which social capital and protective factors within communities could be best utilised for mental health policy and intervention.

Acknowledgments

The authors would like to thank the participants for taking part as well as the public contributors who assisted in the development of the interview topic guide. We would also like to thank Dr Masoud Mohammadnezhad for providing feedback on a draft of the manuscript.