We discuss the results in five separate sections: COVID-19,Anxiety,Age, Education,and Sex.
COVID-19:
Our study does not aim to measure the impact of covid-19 infection and pandemics on the QoL, as it is a aiming to measure the QoL of residents of Zarand city infected with the disease. A city with an underprivileged background and a history of natural disasters. Yet, we can mention how the anxiety during covid-19 might have impaired the QoL when compared to previous findings before the pandemics.
The COVID-19 pandemic has led to loss in Iran until the date of this study and many are infected by the disease[24]. We will discuss the effect of anxiety caused by the COVID-19 pandemics further. Studies have hypothesized the possibility of COVID-19 independently causing depression, anxiety, and sleep problems[25–26].
In the physical domain, COVID-19 is primarily an upper respiratory infection but lower respiratory infection, pneumonia, gastrointestinal infection, fatigability, pain, fever, decreased daily activity capacity and other complaints are also reported[27]. These complaints can potentially affect the physical domain of QoL of our participants (our participants had COVID-19 infection - confirmed by the laboratory test - in two weeks when filling the questionnaire).
People in Zarand are closely connected and social ties are valued in the culture. Iranian ministry of health defined a color map based on COVID-19 outbreak and cities with red COVID-19 status were subject to lockdown and quarantine. The social distancing can impact the QoL in the social domain[28] especially that the interpersonal dependability is valued in Zarand. COVID-19 infected patients were subject to two weeks of quarantine.
The WHOQOL-BREF covers questions on the environmental domain of QoL. Questions number eight (freedom, physical safety, and security) and fourteen (access to recreation and leisure activities) are likely to be affected by COVID-19. Lockdowns, losing jobs, bankruptcy, and inflation resulted in financial difficulties during COVID-19[29]. Access to transportation was also restricted by the government (question number twenty-five).
Anxiety:
We found that anxiety level is correlated with lowered quality of life in COVID-19 infected population. Higher the anxiety, lower the quality of life. The spearman's test proved the correlation significant in all domains with the effect size of moderate between anxiety and physical and psychological domains of QoL and small effect size between anxiety and social and environmental domains. (See Fig. 1, Table 3.) Lee et al.'s found anxiety is related to all dimensions of quality of life[30], although did not find Patrick J. Brown et al. the relationship between anxiety and QoL in the environmental domain[31].
58.8% of our participants reported moderate or severe levels of anxiety that we believe indicates high prevalence of anxiety symptoms in COVID-19 infected population of Zarand city.
Anxiety disorders are a psychological diagnosis and disorders manifesting as excessive worries, irritability, fatigability, and sleep problems[32]. The fear of infection and death has led to reporting of worries and anxiety complaints. Being worried about themselves and the loved ones, COVID-19 might potentially downgrade the QoL scores. We proposed more explanations on how COVID-19 might have impacted the quality of life in the first paragraph in the discussion section.
Age:
We found a positive and significant correlation between the age variable and the physical and psychological domains of quality of life, but it is so weak that it can be ignored. Patrick J. Brown et al. found that increasing age does not always mean a decrease in the quality of life and this applies to the psychological, social, and environmental areas, but the physical quality of life decreases with increasing age[31]. The results of the study by Thadathil et al. on 220 adults over 60 years of age have also shown that physical quality of life decreases with age[33]. Probably, one of the reasons for the discrepancy of the results of other studies compared to our research is that our participants aged from 18 to 58 years, yet diseases are more prevalent in ages above 60, which further impairs QoL.
Education:
In addition, the results of our research showed that there is a positive, meaningful and weak correlation between education level and physical, psychological, and social domains of the QoL. Our findings are consistent with M. Gil-Lacruz et al. and F.Purba et al. showed that higher education, higher quality of life[34–35].
The level of education is a determinant in QoL. Recent research shows that people with lower education suffer from shortage of skill and face a greater risk of job loss, financial challenges, and troubled social life[36]. Furthermore, the evidence indicates that education is an important predictor of health status, employment, decision-making, problem-solving, and critical thinking[37]. All of these highlight the important role of education in QoL.
Sex:
Although the studies of M.Gil-Lacruz, F.Purba, Jinzhuo Hu et al., reported that women have a lower quality of life than men[34–35, 38], we found that there is no significant difference in the QoL between the sexes, In contrast to previous research. The reason might be that, traditionally in Zarand men are more socially involved and women's roles and social activity is limited to the families. Men are also the main source of income in the families. This means that covid may have affected the life of men more than women because the role of men is further limited that of women which were limited even before the pandemics. Yet, there is a limitation in the distribution of sexes in our study. Participants are dominated by women (78% vs 22%, Table1) which even with the statistical correction it may still bias the analysis.
Limitations:
Considering that in cross-sectional studies, specific results may be observed depending on the specific time period in which the research is conducted, these types of studies cannot show the continuity of effects of the covid-19 epidemic on various aspects of people's quality of life. It is suggested that in the future, longitudinal studies should also investigate the relationship between anxiety and quality of life and compare the results with cross-sectional studies. Despite the fact that online surveys were the best method of data collection during the covid-19 epidemic due to the lockdown, the findings may be biased due to restricted access to questionnaires. Participants were between 18 and 58 years old, and older people did not participate in this research that may be due to limitations in affording smartphones and internet plans, and general and digital illiteracy; so it is suggested that the research In the future, attention should be paid to the presence of older people in the research and investigation of the desired indicators. Regardless of age, our study missed populations in the lower social class who are able to afford smartphones and internet plans; there are no exact estimates on the number of missed population but their non-attendance may affect the result, though not significantly.
Despite some limitations of online studies, the findings of our research can provide a perspective on the psychological effects of the covid-19 pandemic on the quality of life and related factors.
The other limitation is that the sex of our participants is dominated by females (Females 58% vs. Males 22%), Although statistical tests are designed to minimize bias but still findings can skew as a result of unequal participation by the sexes.