*3.5. Needs of Persons Who Experienced Isolation/Quarantine*

The mean score for early detection of confirmed cases and persons in quarantine was high in both patients and quarantined persons, 4.51 and 4.44, respectively, and the difference was not significant (*p* = 0.153). Whereas the need for psychological/mental support, financial support, human rights protection, and adequate information was higher in patients than in quarantined persons (*p* < 0.05). However, the need for improving health management of quarantined persons (3.92) was stronger than the need for the improvement of patient treatment (3.79) (*p* < 0.05) (Table 6).

**Table 6.** Needs for confirmed patients and quarantined persons.


footer \* For persons in quarantine due to COVID-19.

The analysis was conducted to examine differences between genders but found no significant difference in either the need for financial support or appropriate COVID-19 related information. However, for the remaining items, the score was higher in women than in men (*p* < 0.05). With respect to between-age differences, the need for appropriate information was not significantly different among different age groups, but the remaining items showed significant age group differences (*p* < 0.05) (Supplementary Table S3).

#### **4. Discussion**

Participants in this study were patients with asymptomatic or mild COVID-19 cases who were treated in a hospital or residential treatment center, and persons quarantined because they had close contact with COVID-19 patients or entered the country from abroad. The participants were from Daegu and Busan, the regions in which the highest number of confirmed cases occurred during the first wave of the COVID-19 outbreak in South Korea (February–March 2020). After the new cases largely declined, we investigated COVID-19 symptoms and precautionary behavior practices (for two weeks before isolation or

quarantine) and psychological states of patients and quarantined persons through a survey. Additionally, we examined the areas in which the participants felt that support would be needed during the isolation or quarantine period.

A break from daily life was the greatest change experienced by individuals due to COVID-19. This experience may have a greater significance, especially at the beginning of an infectious disease outbreak. Our study is of academic significance in that the survey investigated the isolation/quarantine experience of residents of Daegu and Busan, who experienced geographic discrimination and stigma during the first COVID-19 outbreak in South Korea, because a high number of confirmed cases occurred in these regions. Furthermore, the study has significance for the development of health policies in that lessons and implications were derived from the participants' experiences and effort was made to identify the ways to provide other forms of support in addition to treatment.

It is expected that the study findings will help understand the isolation/quarantine experience due to COVID-19 and identify factors that contribute to improving isolation and quarantine environments.

There are a few notable findings in the study. First, 26.2% of patients confirmed to have COVID-19 were asymptomatic. The proportions of asymptomatic COVID-19 patients reported varied, depending on the timing of the study and the number of study participants [28,29]. An asymptomatic case refers to a patient who tests positive on an RT-PCR test, but does not show any COVID-19-related symptoms, such as fever or a cough, either on the day of testing or for the 14 days following [30]. Because symptoms may occur a few days after a COVID-19 test (in which case, the patient is classified as pre-symptomatic), there are limitations in estimating the proportion of asymptomatic patients based on a crosssectional study [31]. Therefore, to avoid overestimating the proportion of asymptomatic cases, a follow-up period of approximately two weeks is required. The participants in this study were those who finished the treatment and, hence, pre-symptomatic patients were not included. The proportion of asymptomatic patients in the study was similar to the findings in a previous study, in which the proportion of asymptomatic cases was estimated by following-up with patients [4].

Second, it was found that the practice of hygiene-related behaviors and social distancing were higher in participants not infected with COVID-19 (that is, quarantined persons) than those confirmed with COVID-19. Particularly, patients and quarantined persons' preventative behaviors differed among items concerning specific practices. For instance, the between-group difference was greater for the item "wearing a mask by ensuring that the mouth and the nose are covered" (3.91 for confirmed persons and 4.44 for quarantined persons) than for the item "wearing a mask during hospital visit" (4.12 for confirmed persons and 4.54 for quarantined persons). Additionally, the level of practicing precautionary behaviors was higher in women than in men, which is consistent with a previous study [32]. However, the difference between genders in practicing precautionary behaviors was not as great as the difference between infected and uninfected COVID-19 persons, and there was no significant between-gender difference in regard to practicing social distancing.

It was reported in the literature that, aside from sociodemographic factors, psychological factors also affect precautionary behavior practices during a pandemic [33]. In a study by Lee and You (2020), individuals who had a higher risk perception of COVID-19 and a higher efficacy of practicing precautionary behaviors practiced personal preventive behaviors and social distancing more rigorously [34]. Accordingly, it is highly likely that, compared to people infected with COVID-19, uninfected people more strongly perceived the severity of COVID-19 infection, and believed that infection could be prevented by practicing precautionary behaviors. Such a difference in perception may have resulted in the difference in precautionary behavior practices, and potentially the difference between infection and non-infection.

Third, the fear of COVID-19 showed different patterns in patients and quarantined persons. Patients were more afraid of social stigma, while quarantined persons feared COVID-19 infection more. In patients, the greatest fear was that they might be socially stigmatized due to the infection and the strongest need in response to COVID-19 was human rights protection. It is likely that their fear of stigma was influenced by the social awareness that individuals are responsible for having contracted the virus. In this study, the perception that patients were responsible for COVID-19 infection was higher in quarantined persons compared to the patients. Likewise, a survey conducted in Gyeonggi Province, South Korea, reported that there was a difference in perception on attribution of the disease between the general public and confirmed patients [35]. If a person believes that individuals have control over whether or not they become infected, he/she will perceive that patients are responsible for the illness [25,36]. The perception that patients are responsible for the cause of illness leads to negative emotions and behaviors toward patients confirmed to have COVID-19, even resulting in prejudice and discrimination [36]. Since stigma around COVID-19 infection affects all areas of patients' lives, the government and healthcare professionals should use public communication to reduce stigma against patients confirmed to have COVID-19, while stressing the importance of precautionary behavior practices.

Whereas, in quarantined persons, the greatest fear was COVID-19 confirmation; the strongest need in response to COVID-19 was early detection of persons who should practice quarantine. Quarantined persons' fear of a diagnosis (of infection) was also reported by Chen et al., who examined the quarantine experience of close contacts of COVID-19 patients [37]. Quarantined persons who were close contacts, not fully informed of the infectious disease, and who experienced infection-related symptoms, had a fear of infection [37,38]. The fear gradually decreased as they acquired more information on the nature of infection during quarantine and tested negative for COVID-19 [37]. However, the quarantined persons in the current study had a fear of infection, even though they did not have symptoms during quarantine and did not test positive. The finding suggests that fear of infection may be a persistent stress factor for quarantined persons regardless of the test result. Hence, central and local governments should follow-up with persons released from quarantine due to COVID-19 to understand their psychological states and support them in utilizing professional psychological intervention programs.

Finally, survey participants expressed a desire for financial support and adequate information during isolation/quarantine. Economic loss due to isolation/quarantine and insufficient information during the pandemic were identified as stress factors in another study as well [16]. If patients and quarantined persons are not guaranteed income (when they cannot work due to isolation/quarantine and afterwards), their livelihoods can be threatened. In particular, because persons with low household incomes are greatly impacted by even a temporary reduction in income, a change in income due to isolation/quarantine can significantly affect their health [39]. South Korea implemented a policy—effective as of 17 February, 2020—that workers quarantined or admitted to hospital due to COVID-19 receive paid leave from their employers, or a living allowance from the government [40]. Nevertheless, survey participants had a high level of need for financial support policy. The reason is believed to be because, in South Korea's current financial support policy, workers who cannot work due to illness are guaranteed to receive merely the minimum level of income [40]. Accordingly, the government should develop a system to help isolated or quarantined persons smoothly return to society, such as resuming work with their employer after recovery from the infection (or after release from quarantine), and not being disadvantaged by the employer's personnel decisions.

While isolated or quarantined, people want to have timely and trustworthy information regarding infection treatment and isolation/quarantine, and feel depression and fear if they do not have access to such information [41,42]. A great majority of survey participants responded that adequate information should be provided for COVID-19 patients and quarantined persons (92.1% and 85.1%, respectively). Approximately one-half of survey participants (55.3% of patients and 45.4% of quarantined persons) responded that they became overly obsessive about obtaining COVID-19 information after conformation of COVID-19 diagnosis or after receiving the quarantine order. Providing accurate information for isolated or quarantined persons to make health-related decisions, namely, empowering them, helps decrease a sense of helplessness and maintain good mental health during isolation/quarantine [42]. Thus, healthcare workers should explain the guidelines for isolation/quarantine and inform COVID-19 patients and quarantined persons of potential negative emotions that may be felt during isolation/quarantine so that they may better cope with the situation.

Our study shows the need for social solidarity and effective communication in the pandemic. COVID-19 patients and quarantined persons are often criticized, discriminated against in the community and at work, or ostracized because they are infected (or had contact) with confirmed patients [43]. An experience of physical and social isolation from society has psychological impacts, including depression, loneliness, frustration, and anxiety, which can persist even after a pandemic ends [43,44]. Not only does the stigma of infection affect personal health, but it is also unhelpful for infection management (from a social perspective). Due to the fear of social stigma, some people may hide the fact that they have COVID-19, avoid immediate use of healthcare services, or forgo adopting healthy behaviors [45]. Accordingly, it is important for public health authorities to provide accurate, persistent, and trustworthy information regarding COVID infections, while simultaneously stressing social solidarity.

From this point of view, our study highlights the importance of strengthening PHEP in a public health emergency, such as a pandemic. PHEP refers to "the capability of the public health and health care systems, communities, and individuals to prevent, protect against, quickly respond to, and recover from health emergencies" [46]. PHEP capabilities include conducting public health surveillance and epidemiological research, providing healthcare services, and performing non-pharmaceutical interventions (e.g., isolation and quarantine), as well as sharing accurate and efficient information, mental health promotion, and encouraging a return to normal daily life [47]. To develop PHEP capabilities, governments and private sectors, non-governmental organizations, and individuals should make continuous and concerted efforts [48].

The current study examined physical symptoms of COVID-19 and the psychological states and needs of patients confirmed to have COVID-19, as well as quarantined persons, and highlighted tolerance and solidarity as ways to cope with infection. The study has the following limitations. First, the study was conducted by using a self-report questionnaire after the isolation/quarantine period was over; thus, the findings may differ from those in an observational study. That is, survey participants may have not remembered the symptoms they had (recall bias) or responded that they practiced precautionary behaviors better than they actually did (social desirability bias). Second, the study findings did not reflect moderate–severe patient experiences. Considering that more than 40% of survey participants were between the ages of 20 and 29, whereas only 5.5% were 60 or older, survey participants seem biased toward younger people, the age group with a relatively higher proportion of mild patients. In addition, because the survey was conducted in the early stage of the COVID-19 outbreak, the level of precautionary behavior practices and the psychological states of the participants in a study conducted at a different time may differ, in accordance with the changes or stages of the public health emergency in South Korea.
