The age of study population was between 34-65 years with an average age of 43 years. Three participants had MA degrees while 17 possessed PHD degrees. In accordance with the purpose of the study, 215 relevant codes were emitted from the content analysis of the questionnaires that in the subsequent step, these codes were divided into 3 main domains including governance factors, individual factors and the factors related to the community and were classified into 21 subdomains (Appendix 1).
In this study, governance factors were identified as the most considerable and comprehensive component affecting the Coronavirus epidemic. Governance factors encompasses 12 subdomains of vaccination, political factors, restrictions, education, support services, administrative services, transportation, health and treatment, culturalization, legislation, management and finance.
Vaccination, as one of the vital strategies to reduce the spread of Coronavirus epidemic, has struggled with many challenges in Iran. Multifarious factors such as absence of public accessibility to vaccines, the loss of valid vaccines and the lack of public satisfaction to the vaccination have significantly hindered the public health efforts to mitigate the impact of the epidemic. Considering the lack of sufficient vaccines in Iran, the process of vaccination has been categorized and it takes a long time for each individual in the community to be vaccinated, which has resulted into the slowing control of Coronavirus. To this point, participant number 5 commented as follow:
"All of the people had no access to the vaccine at the exact time, and at the very beginning the process of vaccination had started with the older age groups. These conditions have caused many people who did not reach the time for their vaccine turn to be frustrated, and occasionally because they were tired of following the protocol, they didn't incline to follow the limitations. The individuals whose relatives died of Coronavirus were depressed and some objected to these existent conditions."
Given the existent of political issues in Iran, and the sour international relations and challenges with other countries, as well as the existence of bank and logistic sanctions, the import of high quality and valid vaccines has been limited. Participant number 15 comment in this regard is noted below:
"For instance, our country cannot receive vaccines or health materials and products from developed countries because of international sanctions, and this has caused the process of vaccination and treatment to be difficult. On the other hand, the government officials promised that the government will produce Iranian vaccine that is not clear how effective it will be according to their statements as we are self-sufficient versus other countries that do not send vaccines to us. Some diplomats recommend holding political and religious demonstrations and other ceremonies as gatherings and elections."
Ratification of legal restrictions is another obtained subdomain in this study. The results of this study demonstrate that factors such as entry of travelers from foreign country without testing and quarantining, the weak implementation the commute restrictions, non-obedience of certain groups from the enacted restrictions, absence of responsible organizations action toward health offenders and lack of staff due to controlling the Implementation of restrictions contributed to the increase of the spread of the pandemic. Moreover another predicament of the legislation is that there is no coherent management for implementation of regulations, and the behavior of the managers indicates dual personality/views toward implementation of regulation.
In this regard, participants number 7 and 20 stated the following, respectively:
"Coronavirus disease is a disease that, given to the essence and nature of the disease, we should be able to prevent from spreading it correctly. We should block it. Blocking should be implemented in a way that martial law must be ordained. Commuting must be limited, in other words the governance must be powerful enough to convince the community that they must stay home. It must be closed everywhere for at least twenty days or one month; when it is blocked for a month or twenty days, the spread of the disease will automatically reduce, and if the governance does not possess this power, this can lead to spreading the disease to a great extent."
"The community is expected to follow the protocols, to the same extent, the government is expected to manage the disease by establishing coherent regulation and maintaining a coherent approach. If a single protocol and word is implemented equally to all of the individuals, the people will obey the regulations to a great extent."
The results of this study demonstrated that in many situations, people may not follow health protocols due to loss of knowledge about the nature of the disease and the ways of its transmission, or, in many cases people abstain from vaccination due to spreading propaganda and lack of adequate knowledge, as per participant number 4 statement below:
"Another factor is related to the knowledge and getting aware of the disease. If we do not have sufficient knowledge and awareness and do not follow the principles of health, this will lead to the spread and transmission of the disease to a great extent, and this can be rooted in beliefs of people. We have knowledge and awareness in some cases but we do not believe, it means that we do not understand the dangers of the disease, in other words we do not know what is threatening us, and we do not feel the danger greatly."
Administrative, public and support services
The findings of this study demonstrated that representing administrative services in a virtual way and the public and support services considered by the government for the people could encourage people to stay at home. This may reduce the volume of traffic and decrease the risk of encountering with the virus in the community. The government should provide financial subsistence and support for people to stay at home thereby reducing the potential violation of restrictions due to economic pressures. On the other hand, providing financial subsistence support packages can have a significant effect on reducing public commuting. In this regard, participants number 2, 5 and 17 stated as follow, respectively:
"In many cases, people throng in banks or organizations and they confront with each other in indoor spaces. Unfortunately, electronic services are not presented to the people and they have to go to these places to meet their administrative and banking needs. On the other hand they have to travel from city to city, and when they travel, they may encounter with the people who are carrier of the disease in a taxi or bus."
"The expense of living in big cities is high. In this situation, the expenses of the conditions related to the Coronavirus disease prevention and treatment are imposed on people as well. Particularly in big cities, it is hard to say that people should not use the subway or bus. These transportation vehicles are also crowded and people do not obey the distance when they sit or stand beside each other."
"Furthermore we should provide the minimum supplies and necessaries of the people. When we say stores should be closed, as some people do not possess good financial capability. At least affluent people or the government can meet their supplies and needs. Eventually, people need income. Their stores cannot be closed by us unless they do not have financial problems. If the government can contribute to them, fewer people will leave their homes."
Health and treatment services
The preparedness of the health care system has a vital role in controlling Coronavirus disease. The health and treatment system must be able to prepare for identifying and screening the patients and this system must possess sufficient equipment, resources, personnel and hospital beds in the case of the outset of epidemic. In many cases the health and treatment system in Iran has encountered with the lack of medicine, hospital beds, oxygen and above all health and treatment specialists in management and controlling of the disease at the beginning of the expansion of Covid-19. In this regard, participant number 14 commented:
"The weakness of the health and treatment system can also be effective in the expansion of the disease. If we do not have diagnostic test and do not be able to screen it will cause the expansion of the disease to a great extent and if our health and treatment system cannot be able to treat accurately, it can pave the way for disease epidemic. Obeying from the health protocols in places as restaurant or shop can be effective in incidence of the disease."
Culture of the community is one of the vital factors in controlling or expanding diseases as Covid-19. The culture of the people in Iran is such a way that it is mandatory to companion (visiting and meeting the elders of the family) or to participate in weddings or funeral ceremonies that these behaviors increase the incidence and expansion of this disease in the community. In this regard, participant number 5 commented:
"The first measure that should be taken in the country via schools and the media is to build a culture in the domain of personal care so that people can notify of the prevention ways. At the very beginning there were involvement of news, media, radio and social media and systemic recommendations were given to the people for disease prevention. It is propagated contradictory statements about the nature of the disease and how to cope with it, especially in social media, and some people believe them though."
Financial and economic policies of the government are effective in controlling the disease to a great extent. Financial contribution of the government as bank cooperation, deferred debt, strengthening charitable organizations financially and the existence of support organizations as the Relief and Welfare Committee to help the families under coverage of the insurance can effect on preventing the expansion of the disease. In this regard, participant number 3 stated:
"Even for the people who live in slums, the existence of health packages as masks and sanitizers can be very effective. There are people who live in difficulty and want to obey the regulations but they cannot follow the route. Financial contributions as providing loan and livelihood contributions and it must be taken action not just words”.
The domain of individual factors was broached as an effective element in relation to Coronavirus epidemic by the interviewers in this study. Individual factors were stratified into 7 subdomains after categorizing and combining common codes.
Understanding the Risk
Understanding the risk of people in community and being aware of the consequences of high-risk behaviors is one of the most vital factors affecting the disease epidemic. On the other hand, the absence of knowledge and awareness of people about the disease, its consequences and control strategies can reduce the understanding the risk of people. In this regard participants Number 1 and 19 commented, respectively:
"Some people as youth or athletes possess the exaggerated courage or fearless as if I am in good condition and I will never get sick and in case of getting infected I will overcome the disease. This wishful thinking and misconception have embedded in his mind and have paved the way for not wearing mask."
"Some people soliloquized that I should call on my friend and relatives and greet them but he did not know that if he has been the carrier of the disease, he would have entangled some other people and if God forbid, the same friends or relatives to be died of the disease, the one will not forgive himself."
The behavior of the people is derived from their personality. People may be dissociable or be possessed high social relationships. A group of people may be parsimonious enough to not buy masks and prevention instruments related to Covid-19. Some people are depressed and tired of following the health protocols and restrictions. These personality features are effective on the behaviors of the people towards prevention from Covid-19. In this regard participant number 6 commented:
"Even some people said apparently that we wear a mask; but it does not go with us and we like to refuse wearing masks. When we got infected to Coronavirus, it is not a problem as we will be treated. Some individuals are tired of this situation and say that I how late I should obey. Maybe this disease may be existed forever. Of course some individuals got along with this condition and accept the Corona protocols as a part of their life."
Another factor affecting on high-risk behaviors during the corona epidemic is lifestyle. Some people live in thickly populated families and communities. Some people smoke, consume alcohol or use drugs, or some people may be weakened physically due to poor condition of nutrition and also their body may be more vulnerable. In this regard participant number 18 commented:
"Some people look the disease more seriously and maybe obey the protocol to a great extent because of their vulnerabilities, as poor nutrition or living at home with the elderly."
The results of this study demonstrate that health condition of people can affect their behavior before Coronavirus disease. People with rare diseases and also the people who are exposed to the risk of health follow health protocols more than the people who are in good health condition. In contrast, the youth and athletes who are in a healthy physical condition show high-risk behaviors before the disease. The participant number 12 commented:
"Families with people who are infected with chronic disease as diabetes, cancer and background diseases, family members try to obey the health protocols to a great extent and also it is seen less commuting in these families."
Factors Related to the Community
In this study, a group of emitted codes regarding the factors affecting the epidemic of Covid-19 in the community were classified into subdomains of social and cultural factors and were embedded in the domain of community-related factors.
Social behaviors as companionships, parties, traveling and visiting are considered as social behaviors related to community norms. Various ethnicities have their own social rituals and behaviors. Moreover, traditional communities in smaller cities rely on their mores to a great extent and do not incline to stop these mores. In this regard participant number 8 and 13 commented as follows, respectively:
"We are a traditional community. We do not quit a series of habits, behaviors and ceremonies, including weddings and funeral ceremonies easily. These situations can pave the way for a more expansion of the disease."
"At the beginning of the disease epidemic, many people quitted important and traditional ceremonies as visiting in Nowruz holidays, as Corona period had been lasted and perhaps the situation had been normalized for the people, this ceremony was held again, of course this ceremony was hardly implemented in the next year."
The culture of communities is one of the most vital factors that can affect the behavior of people. In general, some communities are circumspect and in some other communities, due to the existence of prevailed and old culture of high risk-taking, the high-risk behaviors are common among individuals. On the other hand, changing the culture in some communities is very tough and time consuming, for instance, canceling and avoiding parties and some traditional ceremonies during the disease epidemic. In this regard participant number 11 stated:
"It is probable that some ethnicities and cities may have their own series of regulations. In this condition, it is not important how hard you will attempt as the restrictions are before their culture, you cannot really hope to see following them therefore in everywhere we must know their own cultures and impose restrictions on them."