Coronavirus Disease 2019 Pandemic Effects on Overseas Pakistanis Particularly Residing in China, Saudi Arabia and United Kingdom

Aim This study explored the Coronavirus Disease 2019 (COVID-19) pandemic effects on overseas Pakistani's residing in various parts of the world, particularly in China, Saudi Arabia (SA), and the United Kingdom (UK). Methods This cross-sectional study was completed between November 2020 and April 2021. An online questionnaire was designed and circulated via various social media mediums to overseas Pakistani communities. The obtained data were statistically analyzed through SPSS version 19 for windows. P < 0.05 was considered statistically significant. Results A total of 542 overseas Pakistani participated in the current study. In total, 157 (29%) were females and 385 (71%) males. There were 174 (32.1%), 142 (26.45%), 117 (21.6%), and 109 (19.85%) participants from the UK, SA, China, and other countries respectively. Some participants, or their family members, 93 (17.2%), got infected with the COVID-19. About one-third, 165 (30.4%), of the respondents were afraid that their company would violate their contracts or lose their jobs or be paid less. The majority, 469 (86.5%), believed that the lockdown is increasing their psychological stress. More than half of the participants, 314 (57.9%), stated that the Pakistani embassy did not facilitate them in their country of stay. About one-third, 194 (35.8%), of the respondents faced visa-related issues. More than one-third of respondents, 221 (40.8%), faced health issues due to lack of physical activities during the lockdown. Males were afraid that their company would violate their contract, lose jobs, or be paid less than females (p < 0.001). Both genders had psychological stress and health issues because of the pandemic. The participants from SA faced more visa-related issues, and they were less satisfied with the efforts of the Pakistani embassy to facilitate them compared to the UK and China participants (p = 0.013). Conclusion Our data indicate that the COVID-19 pandemic impacted Pakistanis living in the UK, SA, China, and other parts of the world. They had health-related issues, visa problems and dissatisfaction with Pakistani embassy facilitations. Pakistanis living abroad require government assistance to resolve their issues.


INTRODUCTION
In late December 2019, a highly transmissible and pathogenic coronavirus named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, and caused an outbreak of unusual viral pneumonia. The virus has expanded beyond the borders and caused a pandemic designated Coronavirus Disease 2019 . This ongoing COVID-19 pandemic has threatened health care systems, public safety, animal, environmental and human health (1)(2)(3). Because of the devastating effects of the COVID-19, overseas workers and their dependents are socially and economically vulnerable. Furthermore, lockdown, quarantine, self-isolation, and social distancing have significantly affected the overall mental, physical and social wellbeing (4,5).
Pakistan has a population of ∼2,200 million people, and ∼8.4 million people live in other countries as immigrants or expatriates. Aside from that, thousands of Pakistanis are holding the student visas. Pakistan is one of the top 10 recipients of international remittances. In 2019, Pakistan received USD 21.8 billion in foreign remittances, accounting for ∼8% of its GDP. In this way, overseas workers are directly contributing to the country's socio-economic development. The top five countries from where the overseas Pakistanis send remittances are Saudi Arabia (SA) (23%), United Arab Emirates (UAE) (21%), United Kingdom (UK) (16%), United States of America (USA) (16%), and other Gulf Cooperation Council (GCC) countries (10%) (6).
According to government sources, nearly 4.7 million Pakistanis are working in the Middle East (7). Many expatriates faced unprecedented challenges and psychological symptoms across geographies during the COVID-19 pandemic (8,9). The migrant workers in several countries were suffering from unemployment, social discrimination, financial hardship, and mental stress during the COVID-19 pandemic (10). This demonstrates how the pandemic has significantly impacted people's mental health, particularly among expatriates. In the COVID-19 pandemic all over the world, expatriates and workers faced several problems.
However, the current COVID-19 pandemic effects are widespread and have forced enormous pressure on people from all backgrounds or professions, including healthcare workers, students, security forces, and the general public, thus resulting in high psychological symptoms including anxiety, depression, fear for their safety, higher levels of stress, insomnia, negativity, poor sleep and somatization (4,(11)(12)(13)(14). Thus, the current study was conducted to explore the COVID-19 pandemic effects on overseas Pakistani's residing in various parts of the world, particularly in China, SA, and UK.

METHODOLOGY
This cross-sectional study was conducted from November 2020 to April 2021, and data were collected from the overseas Pakistani people residing mainly in China, SA, UK, UAE, Malaysia, USA, Canada, and other countries.
A brief description was provided regarding the study questionnaire, its purpose, and instructions on how to complete it before completing the survey. Before proceeding further, all participants were required to express their willingness to volunteer for participation by answering yes or no and filling out the questionnaire was also considered their consent. Participants were asked if they would be willing to participate by answering "yes" or "no." Furthermore, if participants did not wish to continue, they were given the option to withdraw at any time. All participants were assured that their identity would not be disclosed, and data will be used only for research purpose. The sample size was calculated on sample size calculator from calculator.net (https:// www.calculator.net/). There was a need of 385 samples to have a confidence level of 95% that the real value is within ±5% of the measured/surveyed value. The sample size was increased to improve validity and generalizability.
A snowball sampling technique was employed to recruit participants. Using Google Forms, an online self-reported questionnaire was created. The survey link was sent to the investigators' contacts via WhatsApp, Facebook, Instagram, WeChat, email, and other social media platforms, and participants were encouraged to forward it to Pakistani friends' circles residing in their country of stay.
The questionnaire had several parts. The first part contains demographic information about gender, education, employment status, country of stay and infection of coronavirus. There were several questions about the impact of the COVID-19 pandemic and lockdown like fear, anxiety, stress, fear of unemployment, and salary reduction. There were questions regarding their or their family members' infected with COVID-19 and treatment in a hospital in their country of stay. There were questions about the visa problems and facilitation by the Pakistani embassy in their country of stay. The consequences of lockdown on their health,  their family health reside in Pakistan, and their satisfaction with the Pakistan government to manage pandemic in Pakistan. The format of the questionnaire was "yes, " "no, " or "maybe." The questionnaire was prepared in English and Urdu languages, and before distribution, its content validity was done by two senior professors and one medical educationist. It was modified as per their suggestions. A small pilot study was conducted, and participants were requested to point out any flaws and ambiguity in the questions. There were 40 participants in the pilot study. In this way, the comprehension and correctness of the questions were checked. The reliability of the questionnaire was calculated by Cronbach's alpha (Alpha = 0.78).

STATISTICAL ANALYSIS
The information was gathered for each participant in Microsoft Excel 2019. The obtained data were analyzed using SPSS version 19 software for windows. The Chi-square test was applied to assess relationships between various variables. Moreover, the qualitative variables are expressed as frequencies and percentages. P < 0.05 was considered statistically significant.
A small number of our study participants, or their family members 93 (17.2%), got infected with the COVID-19. Half of the study participants, 273 (50.6%), were not aware of hospital treatment quality. About one-quarter of the respondents, 151 (27.9%), stated hospital treatment is good. Most of the participants, 453 (83.6%), believed that a decrease in personal income is causing anxiety and fear of unemployment in lowwage workers. About one-third, 165 (30.4%), of the respondents were afraid that their company would violate their contracts or lose their job. Almost half of the participants, 267 (49.3%), were stressed that they are being paid less due to lockdown. The majority, 469 (86.5%), believed that the lockdown is increasing their psychological stress. More than half of the participants, 314 (57.9%), stated that the Pakistani embassy did not facilitate them in their country of stay (Figure 1).
About one-third, 194 (35.8%), of the respondents faced visarelated issues. Most of the participants, 440 (81.2%), worried that their family members living in Pakistan would be infected by coronavirus. About two-thirds of the participants, 340 (62.7%), were satisfied with the current management of the Pakistani government about COVID-19 (Figure 2).
More than one-third of respondents, 221 (40.8%), faced health issues due to a lack of physical activities during the lockdown. One-third of the respondents stated that the people who have no company responsible for their health insurance should return to their country ( Table 1).
In total, majority of the male participants were doctors, laborers, and businessmen, while majority of the females were teachers. More males were afraid that their company would violate their contract, lose jobs, or be paid less than females (p < 0.001). Both genders had self-perceived psychological stress and health issues because of the pandemic. Females were more satisfied than males with the current management of the Pakistani government about COVID-19 (p = 0.022) ( Table 2).
The study data were analyzed country-wise by including people from three countries, i.e., UK, SA, and China, because more than a hundred participants were in each group. More females participated from UK and SA compared to China in the survey, and more males were from China compared to the UK and SA (p < 0.001). There were more undergraduate subjects from SA compared to UK and China. There were more postgraduates from UK and China compared to SA (p < 0.001) ( Table 3).
A significantly higher number of study participants suffered from COVID-19 from UK and SA compared to China (p < 0.001). The participants from the UK praised the quality of hospital treatment compared to KSA and China (p < 0.001). The participants from all three countries believed that decreasing personal income among low-wage workers is causing anxiety and fear of unemployment (p = 0.904).
Most of the participants from the UK were satisfied that their company would not violate their contract or terminate them, or they will be paid less compared to SA and China (p < 0.001). The participants from all three countries admitted that this pandemic is increasing their psychological stress (p = 0.306). The participants from SA were less satisfied with the efforts of the Pakistani embassy to facilitate them in their country of stay compared to the UK and China (p = 0.013). The participants from SA faced more issues related to visas compared to UK and China (p = 0.051). Compared to the UK, most of the participants from SA and China were worried that their family members living in Pakistan would be infected with COVID-19 (p = 0.001). Participants from the UK were more satisfied with the current management of the Pakistani government about COVID-19 (p = 0.002), and they were facing fewer health issues due to lack of physical activities (p = 0.005) ( Table 3).

DISCUSSION
The majority of participants (83.6%) believed that decreasing personal income causes anxiety and fear of unemployment in low-wage workers. Approximately one-third of those polled were concerned that their company would breach their contracts and cause them to lose their jobs. Almost half of the participants were concerned that they were being paid less because of the lockdown. The majority of people believed that the lockdown was increasing their psychological stress. Additionally, because of the pandemic, both genders experienced psychological stress and health problems.
A study among Indian expats working in SA, UAE, Qatar, and other GCC countries reported higher anxiety and depression among the participants because of COVID 19 pandemic effects. During the pandemic, more than one-third of the participants were affected by the ban on air travel (15). They also reported a significant association between subjective concern with air traffic restrictions during the COVID-19 pandemic and the level of anxiety and depression (15). Some studies reported a higher level of depression among expats during the COVID-19 pandemic than previous studies conducted among the expat population prior to the COVID-19 pandemic (15,16). Our results are similar to Saudi studies that observed a high prevalence of psychological symptoms among expatriates during the COVID-19 pandemic (9,17). This demonstrates the pandemic's significant impact on peoples' mental health, particularly among expatriates. A study from UAE, explained that the government's preventive measures and several restrictions imposed for the public were the most likely reasons for expatriate worries and stress. Since the pandemic, expats' residents have been unable to travel to their home countries on vacation. They have been unable to participate in any outdoor group activities on weekends or in their spare time (18). It seems that because of the prolong lockdown and travel ban, they were confined to their residences, which also affected their mental health. Most overseas Pakistanis recognized and valued the measures taken by SA, UK, and Chinese governments to support and deal with the pandemic. Despite this, anxiety, stress, and uncertainty were reported. Similar findings are reported among UAE expatriates' residents (18). One-third of those polled had visa issues. It happened because all countries shut down their flight operations and imposed a travel ban on their citizens. Several people who wanted to travel to their home country for vacation or to attend some events encountered visa issues and could not travel. Most overseas Pakistani children study in Pakistan or other countries, and the travel ban has caused them to be stranded, adding to their anxiety and stress. Furthermore, their visa had expired. As a result, there were numerous factors exacerbating anxiety among overseas workers. Most overseas Pakistanis were concerned that their family members in Pakistan would become infected with coronavirus. This could be because people in Pakistan were not strictly adhering to World Health Organization (WHO) guidelines; they had inadequate knowledge and were not strictly adhering to social distancing and ignoring the severity of the issue (19,20).
The Pakistani government took great initiatives didn't go for complete lockdown despite severe opposition political parties' pressure. The federal government resisted the call of complete lockdown in the country because of the extreme poverty and abundance of daily wages workers (5). We inquired about the Pakistani government's efforts to manage COVID-19 in Pakistan because, as overseas Pakistanis, they are in an advantageous position to compare the Pakistani government's efforts with their country of residence. Furthermore, they maintain constant contact with family members, relatives, and friends in Pakistan, and they are aware of the Pakistani government's efforts through news channels and social media. About two-thirds of the overseas Pakistanis were satisfied with the Pakistani government's efforts to manage COVID-19 in Pakistan.
More than one-third of respondents reported health problems due to lack of physical activities during the lockdown. Initially, SA, UK, and China imposed complete lockdown. People had extremely limited movement, and they were only allowed to go to nearby grocery stores or bakeries to buy their daily needs, and because of extreme fear, people were going out of home once a week, or fortnightly. This physical inactivity, combined with the extreme fear of contracting a coronavirus infection, caused widespread psychological distress. People were also afraid to go to hospitals for routine checkups or minor problems for fear of contracting a coronavirus infection (21). The daily news on social media about coronavirus infection and deaths added to their anxiety, and they were confronted with many health-related issues (22).
In comparison to China, the UK and SA had a significantly higher number of overseas Pakistanis infected with COVID-19. In comparison to SA and China, the participants from the UK praised the quality of hospital treatment. Despite the fact that the COVID-19 began in China, the Chinese government handled it meticulously after the first wave. Then, due to isolated incidents, the total death and infection rate remained low compared to other parts of the world (23).
Our study participants' response regarding the quality of hospital treatment can be explained based on a WHO report that stated that the UK healthcare system is ranked 18 th in the world, while SA and China are ranked 26 th and 144 th respectively (24). The UK is ranked the best healthcare system in the world overall in a 2017 report by the Commonwealth Fund ranking developed-country healthcare systems (25).
The Pakistani embassy provided the early services and facilitated (issues like visa, passport renewal, national ID card renewal, and so on) 48.7%, 32.4%, and 46% of the study participants from China, SA, and the UK repectively. In comparison to the UK and China, participants from the SA were less satisfied with the Pakistani embassy's efforts to assist them. Participants from the SA encountered more visa issues than those from the UK and China. Our results are reflected by a few months back Pakistani governments step to call back ambassador and six officers of Pakistan Embassy in SA over Pakistani community complaints (26). Many Pakistan expats working in SA and their children are studying in Pakistan or abroad, and during the COVID-19 pandemic, all have faced visa and travel problems.
Participants from all three countries agreed that a drop in personal income among low-wage workers causes anxiety and fear of losing their jobs. A study reported that expats were terrified of losing their jobs and running into financial difficulties (18). As a result of living with the coronavirus, people are understandably concerned about their health. A study reported two major reasons for this rampant and severe fear; (a) the lack of a curative drug available to date, the fear of health consequences is growing and becoming a major concern, (b) the increasing number of deaths worldwide. As a result, even those who have not been infected with the virus are concerned about their health and wellbeing, and another deeply felt concern is the threat of job loss and a financial crisis (18).
The COVID-19 pandemic imposed a prolonged lockdown period, wreaking havoc on the business and economy and displacing thousands of people (27). Therefore, the probability of job loss all over the world has been high. It has also become extremely difficult for people to find new jobs due to the coronavirus's destruction of the economy. This resulted in high levels of job insecurity for expatriates (18).
Several studies have reported that the fear of job loss and financial loss are significant sources of stress among people living in pandemic conditions in Pakistan, India, and SA (14,28,29). Our results are similar to studies from UAE and SA. A study from UAE reported that most Asian respondents were more severely worried about job insecurity than the Arab and Western expatriates (18). Asian expatriates may not have a good chance for new appointments, job-shifting, or re-employment in the emerging declining labor market conditions caused by the COVID-19 pandemic. As a result, the Asian community was more concerned about their job prospects than the Arab or Western expatriate residents (18). Asian expatriates in SA were also worried about the loss of jobs (29).
The pandemic's health risks are beginning to recede in some areas, and the people are being vaccinated, but still, people have hesitancy about getting the vaccine (30), and it is unclear how long the crisis will last and its long-term impact. New ways of working remotely and concerns about the global recession will continue to create uncertainty (8). Many people were worried about the health consequences, fear of losing jobs, restrictions on international travel, and fear of isolation. Even when an efficient governmental system for preventing and controlling the pandemic is in place, the difficulties that the coronavirus has presented continue to ravage people's psychological wellbeing (18).
Although the development of vaccines and widespread immunization campaigns provide some solace, the psychological scars of the pandemic are likely to last for a long time (31,32). The most pressing and critical need in this situation is to provide financial and social security to workers abroad and those who have returned to their home countries (10). It is suggested that to alleviate stress, anxiety, and devastating effects of COVID-19 in overseas Pakistanis, they should be connected with family and friends and practice meditation and regular exercise. Yoga and meditation are also thought to be effective methods of increasing positive energy and improving mental health. Regular meditation or yoga practice may help emotionally sensitive people become calmer, more relaxed, and more stable (18). The government of Pakistan should take immediate steps to help overseas Pakistanis problems through community help and support centers in consulate offices.

LIMITATIONS
There are several limitations to the present study. Firstly, its sample size is not large enough. Secondly, sampling techniques and online collection of data have selection bias. Thirdly, in such types of studies, no cause-and-effect relationship can be drawn. Fourthly, we did not use any psychological inventory to measure study participants stress and anxiety.

CONCLUSION
Our findings show that the COVID-19 pandemic affected the overseas Pakistani's residing in the UK, SA, China, and other parts of the world. Participants in the study encountered health-related issues, and visa problems. They were dissatisfied with Pakistani embassy facilitations. Overseas Pakistanis want government aid to settle their problems.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

ETHICS STATEMENT
This study was approved by the Ethical Committee Abbottabad University of Science and Technology (Registration No. F.No/AUST/micro/0460).

AUTHOR CONTRIBUTIONS
TA, BM, and FA: conceptualization, study design, and questionnaire. TA, BM, FA, MM, MB, AI, FB, JB, MS, and AS: data collection. TA and MB: preparation of first draft, data analysis, and editing and proofreading. BM, FA, MM, AI, FB, JB, MS, and AS: helped in manuscript writing. TA: supervised the study. All authors significantly contributed to this study and approved the final manuscript for publication.