Reviewer’s report
Title: 
Psychosocial, emotional and professional challenges faced by female
healthcare professionals during the COVID-19 outbreak in Lahore, Pakistan: A
qualitative study
Version: 
1 
Date: 
01 Mar 2021
Reviewer's report:
This paper addresses an important topic and brings the experience of female
HCPs in Pakistan into a global conversation about the experience of HCPs
during the pandemic. The data is rich was collected at an interesting moment in
the pandemic. On this basis I believe the paper will be able to make a useful
contribution to the literature on HCP experiences of pandemics and so have
recommended major revisions. 
The strength of the paper is that it gives an overview of the challenges faced as a
female HCP in Pakistan during the pandemic. This in turn sheds light on the
importance of having policy measures (such as appropriate quarantine options)
which reflect the realities of socio-cultural aspects of family life and the specific
experiences of Pakistani women. Bringing this into conversation with the wider
literature on HCPs experiences in general and female experiences in particular
during the pandemic could make an important contribution to the literature on
emergency response. 
The weakness of the paper is in the construction and articulation of this
contribution across the piece. There are several areas for further clarification
which would help to bring this contribution into view:
a) The context of this paper within the wider literature 
b) The framing of the question that is being addressed
c) The methodological approach taken
d) The conclusions drawn through analysis 
These 10 questions (taken from Patriotta, 2017:
https://doi.org/10.1111/joms.12280) can help with establishing your contribution
before you redraft the paper. You already have the answers to most of these
questions within what you have written, but this exercise can help with
generating a coherent structure for the paper. 
1. This is what I am focusing on 
2. This is why it is relevant 
3. This what is known/know known (and why it needs attention)
4. This is my burning question
5. This is how I aim to address the question (theoretically/empirically)
6. This is what I did
7. This is what I found 
8. This is what it means
9. This is what I add
10. This is why you should care 
I suspect that the preparation of the paper was rushed. I appreciate that it is
desirable to get results of research about the pandemic published in a timely
fashion, but taking more time over the framing and analysis would help to clarify
exactly what subject the paper is addressing and what contribution it makes in
doing so. To me, it feels like a draft-in-progress rather than a paper for
submission. Another round of analysis and editing will bring it to a better
standard. Also, while I am aware of the unfair primacy of English as the
language of academic publication, the paper would benefit significantly from
being proof-read for accuracy and fluency of English 
I have provided some specific feedback on different sections of the paper. As I
anticipate overall revisions will be done across the paper these can be taken as
suggestions rather than directions. 
Background 
The paper would benefit from a much clearer framing of the issue being studied.
There are three components to this: 
- A comprehensive review of the existing literature, what is known and what
remains unknown. The reference list has some interesting and relevant papers
that likely have insights that will be relevant for framing this study. There is now
a great deal that has been published on about the burden shouldered by HCPs
during this and other pandemics and the specific role of women within them. It is
important to join this literature and say how this paper hopes to build on it. 
- A clearer description of what you mean by 'psychosocial'. What definition or
explanation of psychosocial is being used? Given the range of subjects covered
in the analysis - HCPs emotional experiences of the pandemic, social and cultural
attitudes towards women, women's roles in family and professional life, and
structural issues relating to government/hospital responses to the pandemic - I
would suggest that a different, broader term would be beneficial. A crucial factor
that seems to have defined the experience of female HCPs in Pakistan in your
paper is the issue of quarantine. This is not in itself a psychosocial issue, it is a
policy/structural issue. I would recommend thinking again about what the
analytical subject of the paper is in light of this. 
- A general overview of the experience of HCPs in Pakistan during the
pandemic. What were some of the policy decisions, e.g. around quarantine? It
would be useful background for the paper to provide a description of the policies
implemented and how they affected women in order for readers to be able to
compare with their own country context. 
Methods
In a similar vein to the potential misuse of the term 'psychosocial' to describe the
focus of the paper, I also think that you should rethink the framing of analysis as
phenomenological. The approach to analysis does not reflect my understanding
of a phenomenological approach, and instead reflects an applied approach to
qualitative thematic analysis. For example, you write of an 'inside perspective' in
line 68 - but in what way is this different from other qualitative approaches,
which all seek to understand the narratives and perspectives of participants? You
mention that both phenomenological and thematic analysis were done - what was
the rationale for this? 
The methods could be usefully clarified by including more references to the
methodological literature that informed the study. Simplifying the study
description and providing more detail on exactly what was done - in both
methods and analysis - would make the paper easier to interpret. If you'd like the
retain the focus on phenomenology this would need to be much clearer about
how the study is phenomenological in the methods and throughout the analysis. 
The description of the study procedures is very clear. With regards to the
sampling, it would be useful to know more about how you found the participants.
How were they invited? 
Results 
I think that refocusing and clarifying the purpose of the paper will lead to a
different interpretation and structuring of the results. I will make some general
comments that may help with this and a few specific comments on clarity/style. 
- Overall, it is not always clear in what way the participants' experiences as
women are central to the analysis. Some of the findings are certainly specific to
female HCPs, but many of them are likely relevant for all HCPs (or seem to
reflect the experience of HCPs in the literature). If the focus of the paper is the
experience of female HCPs, issues that affect them specifically as women should
be brought to the fore.
- As I mentioned above, a stronger grounding in the existing literature on HCPs
experience of the pandemic would help to identify what is novel about the
experience of female HCPs in Pakistan, and what can be learnt from the data
collected for this study. 
- The focus on psychological concerns in Theme 1 doesn't seem to describe the
data that is included within it. You highlight a wide range of concerns - fear of
infectiousness/ experiences of life outside of work - with family and with the
public. I recommend either a you provide clearer definition of what constitutes a
psychological concern or you reframing of the theme. There could also be more
data within this section. 
- Theme 2 seemed important to the experience of female HCPs. I wanted to
understand more about why counselling family members (I assume that attendant
meant visitor - this should be clarified) was a difficult task for female staff in
particular. Why did they have a different experience to male staff? I was also
interested in the point about inequality in decision-making and access to
treatment - how did your participants talk about these issues and what we learn
from that about their experience of providing care during the pandemic? 
- Theme 3 brought in several important issues to do with government, training
and institutional support, but I was unsure how these related to the stated aim of
exploring the psychosocial impact of the pandemic. From this section I think it
would be particularly relevant to draw out the experiences of pregnancy for
female HCPs during the pandemic. 
- Theme 4 clearly addressed the experiences of women. It provides important
information about space for changing clothes, issues of protection and safety,
quarantine, family responsibilities. When re-drafting the paper it might be useful
to start with this theme and see how it could provide an overarching structure for
the analysis. I was unsure what this sentence means (265-266): For that reason,
they needed additional family tantrums by daily requesting their spouses to drop
them, because of missing driving licenses among women
- The future concerns and recommendations in theme 5 were clear but could
perhaps be tied in with other themes. 
- In a few sections you mention self-confidence and determination - it would be
useful to see data to support these points and to reflect on what this means in
light of the overall challenges faced by women during the pandemic. Why was it
important for your participants to highlight these positives? How did they
connect to the negatives they experienced? 
- I would remove percentages and add a table of participant characteristics.
Discussion 
In a discussion section I would expect to see the authors return to the research
question and revisit the initial focus of the paper in light of what they have found
through their analysis, showing how this makes a novel contribution to the
existing literature on that topic. I think this has proved to be a challenge in your
paper, as I am not certain you have a focused enough research focus (as
discussed above) and you have not outined the literature to which you hope to
make a contribution. Some of the issues you have rightly identified as important
for consideration in the experiences of female HCPs, such quarantine
procedures, are not to my understanding psychosocial problems. 
It would be useful to reflect on in what ways these were similar to the
experiences of female HCPs in other countries and in what ways they were
difference. This would help to elucidate the specific contribution this paper
makes. 
You mention the need to address rumours but this did not come out strongly
through the data - could be important but would need more data on this. 
While I agree in principle with the recommendations I would like to see stronger
connections to the findings from the data. I wonder what the HCPs themselves
identified as important issues that needed to be addressed through policy change.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes