According to a study by the Instituto de Saúde Pública da Universidade do Porto (ISPUP), the COVID-19 pandemic completely transformed, throughout the world, funeral rituals and customs and this change had a significant impact on the grieving process of each individual and had consequences on their mental health.
The study aimed to find out the thoughts and feelings of Portuguese adults who had suffered the loss of a loved one since the beginning of the COVID-19 pandemic and how this loss impacted their daily lives.
“The new coronavirus has been responsible for increasing the death rate worldwide and radically changing the lives of all individuals. Added to these changes is the fact that people cannot be close to their loved ones in the event of illness, near the deathbed, during funerals, and at times of greater frailty,” explains Ana Aguiar, first author of this study. She is an ISPUP researcher in the Epidemiology of Mycobacteria Infection, HIV and other Sexually Transmitted Infections laboratory, belonging to the associated Laboratory for Integrative and Translational Research in Population Health (ITR), coordinated by ISPUP.
The research was published in the scientific journal Plos One. It was conducted from data collected through a structured online questionnaire, which was posted on social media, and was active between November 2020 and February 2021.
Out of a total of 929 people who completed the questionnaire, 752 (80.9%) did not report any loss of a relative, friend or acquaintance. Only the remaining 166 (17.9%), who reported having lost someone since the beginning of the pandemic, were considered for the present study. The majority of the participants involved were women (66.9%), the average age was 37.3 years and about 70% had a high education degree.
Of this sample, 28.3% had lost grandparents, about 22% a friend, and 9% had lost a parent.
It was found that participants who were going through a bereavement experience had a high prevalence of anxiety (30.7%) or depression (10.2%) symptoms, both with higher expression in women. Additionally, it was found that post-mortem procedures played a preponderant role in the individuals’ grieving process.
Of the 166 participants who said they had lost someone since the start of the pandemic, 85 responded to the following open-ended question “To what extent has your loss impacted your daily life?”.
Through content analysis of the responses provided, the researchers identified four major themes, which summarise how Portuguese adults experienced their loss in various domains: the perceived inadequacy of the funeral rituality; sadness, fear, and loneliness; changes in sleeping and concentration, and increased levels of anxiety; and concerns regarding the pandemic situation.
The isolation and quarantine measures, as well as the prohibition of people congregating in the same place, led to a ban on visits in hospitals and health establishments and to the impossibility of participating in funeral rites.
“People could neither express their feelings of loss nor say a proper goodbye to the person who had passed away. In this way, feelings of uncertainty were exacerbated and losses became ‘ambiguous’ as the bereavement experience proved incomplete,” says Ana Aguiar.
The testimony of a participant who lost a best friend’s aunt, father, and mother exemplifies the impact that changes in funeral rituals have had on the grieving process: ” Worse than the loss itself is the fact that we cannot mourn, we cannot attend ceremonies, we cannot comfort family and friends and receive consolation, we do not have the opportunity to be distracted in any way, the global news is slow to improve.”
Feelings of sadness, fear, and loneliness were common among participants. Individuals reported that they thought more about their health and their own death and that they were afraid of losing a loved one. Moreover, they revealed that they were afraid of how the future had changed, how the pandemic situation had completely altered their way of living, and the fact that they realised that that person was no longer part of their lives.
Grief is intrinsically linked to loneliness, and the closer the lost loved one is, the more overwhelming this feeling is. The testimony of a woman who lost her spouse gives an account of the loneliness experienced when losing a very close loved one: “Everything. The lack of everything. The loneliness.”
Anxiety is a natural response of the body to a loss and makes individuals feel more vulnerable and question more about the unpredictability of life. “The emptiness caused by the loss and the unfinished grieving process can have a continuous and devastating impact on the daily behaviours of the bereaved affecting their work and long-term mental health,” indicates Ana Aguiar.
Another participant who lost her father during the pandemic said that her behaviours were altered during the bereavement process and that she felt changes: “In different aspects: not sleeping, not being able to concentrate or think clearly, compulsive eating, frequent anxious moments. Increased impulsiveness and lack of motivation for all daily tasks. Lack of empathy/patience”.
All people were affected by the pandemic situation in very different ways, depending also on the person’s own lived experience, individual functioning, and life context. The uncertainty about the future of the pandemic situation in analogy with their losses worried the participants who answered the research question.
Also the temporary passage through life unsettled individuals. A final testimony from someone who lost a grandmother shows that reflection on the cycle of life was something common during this period: “It made me realise how ephemeral we are”.
The first author of the study reinforces the message that “grief, the way in which grief has been altered, and all the difficult processes that grief involves, can influence our ability to move on and get on with our lives.”
She adds that “if this process is not managed well or if it does not go through the different steps associated with bereavement, it can actually increase the risk of mental health problems, which can lead to complications such as depression, anxiety, and long-term post-traumatic stress or even long-term bereavement disorders.”
Grief is a long process composed of phases that must be respected – denial; anger and rebellion; negotiation; depression and mourning for the life that was lost; and, eventually, acceptance. In a pandemic period, this process was destabilised and became incomplete.
According to Ana Aguiar, public health professionals have an essential role in the creation of support strategies and tools together with colleagues in the area of psychology. Mobilising a multidisciplinary team of professionals who plan beforehand responses for people who are going through a bereavement process can have very beneficial effects on the population’s well-being.
“Public health cannot forget the issues of bereavement. We are still in time to help people who have lost and continue to lose family and friends,” she stresses.
This study was entitled “A qualitative study on the impact of death during COVID-19: Thoughts and feelings of Portuguese bereaved adults“. The researchers Raquel Duarte (ISPUP) and Marta Pinto (Faculty of Psychology and Education Sciences, University of Porto) also participated in the study.
The research is part of Ana Aguiar’s PhD project, which received funding from the Portuguese Foundation for Science and Technology (FCT) and the European Social Fund Program.