Citizens’ Expectations from Government in Response to COVID-19 Pandemic: A cross-sectional study in Iran


 Background: The government is the main body in charge of controlling epidemics; hence, expectations from government’s intention and capacity would affect citizens’ behavior and flexibility. Given the severity of COVID-19 pandemic and an urgent need for people's cooperation in the prevention and combat processes, understanding the public perspectives would be crucial and instructive. This study aimed to explore such perspectives towards the current pandemic among the Iranian. Indeed, we sought to provide a favorable platform for effective policies in the face of the COVID-19 pandemic by recognizing public expectations.Methods: This is a cross-sectional survey and text data were collected in three areas. We used an open-ended online questionnaire to investigate the common perspectives of the Iranian towards government’s response to COVID-19 pandemic. The participants were selected using snowball and convenient sampling techniques across the country. The collected data were analyzed and described using thematic content analysis. Results: In general, 2547 participants agreed to participate in this study and completed the online questionnaire. According to the findings, the Iranian exhibited several expectations regarding the government's response to COVID-19 pandemic, based on which three main themes were extracted: (1) health-related expectations, (2) policy-related expectations, and (3) mass media-related expectations. In this study, a majority of the participants highlighted the need to consider and follow-up the patients and their families, provide financial and hygiene support during the pandemic, apply strict restrictions, and have close monitoring and controlling procedures. Furthermore, they mentioned that authorities and news agencies should observe honesty and transparency principals.Conclusions: Our findings revealed that people expect the government and other responsible institutions to minimize the burden of this pandemic on them through adopting effective policies. The study findings could help policy-makers become aware of people's expectations and develop better strategies.

December 2, 2020 [2]. Iran's government immediately developed and implemented several strategies and policies, including social distancing, prohibition of unnecessary trips, and closure of educational centers, to combat this outbreak [5]. Although the adopted measures had positive effects on pandemic control [6], they also created serious problems and challenges to the society, especially the poor and vulnerable groups. More importantly, due to the imposition of international sanctions on Iran throughout the last decades, the negative effects of this pandemic on the already-weakened economy were enormous [7].
Evidence suggests that epidemics such as COVID-19 have signi cant economic and social consequences such as unemployment, poverty, and stigmatization [8]. The United Nations (UN) and other international organizations have predicted that the negative economic impacts of this pandemic are harsh, especially for developing countries [9,10]. A rise in the domestic violence is another consequence of COVID-19 outbreak [11]. Following containment measures, a 30% increase in domestic violence has been reported in Europe [12].
Sociologically, policy effectiveness and the governance agenda in crisis are the citizens' main expectation in this modern public sphere. Protecting the citizens' lives is one of the rst duties of governments, which also shapes the citizens' public expectations. Such expectations seem to affect how citizens form their behaviors and attitudes toward public services [13]. In public health emergencies arising from an infectious disease epidemic, the government is in charge of protecting the community residents by preventing the spread of the disease [14]. The citizens' expectations from what the government is capable of doing and what policies the government authorities intend to pursue can in uence their decisions [15]. Government is also responsible for regulating and controlling health activities and services as well as sanitary and epidemiologic surveillance [16].
In the previous study investigate social concerns regarding the COVID-19 pandemic and this concern has been raised from different perspectives. For example, Nelson et al. (2020) assess public concerns about the COVID-19 crisis in the United States before shelter-in-place orders were widely implemented [17]. A new study of public attitudes across Europe, America and Asia has found that people in the UK have the highest overall levels of concern about coronavirus -more than Italy or Spain -while those in South Korea are the least concerned [18]. Stokes et al. (2020) claimed that public response to the pandemic is important, but under measured and it could lead to earlier recognition of changing public priorities, uctuations in wellness, and uptake of public health measures, all of which carry implications for individual-and population-level health [19].
The formulation and adoption of effective, equitable, and community-based policies must be considered to diminish the burdens of such epidemics [20]. Since policy-makers' awareness of the public perspectives and viewpoints is of utmost importance in developing and performing the strategies and programs, engaging individuals in this process is essential as well [21]. Given the severity of COVID-19 pandemic and the double need for individuals' cooperation in the process of controlling this pandemic, understanding the public perspectives would be crucial and instructive. This cross-sectional survey aimed to explore such perspectives towards the current pandemic among the Iranian. Indeed, we sought to provide a favorable platform for effective policies in the face of the COVID-19 pandemic by recognizing public expectations.

Study design and setting
This is a cross-sectional survey that text data were collected in three areas using an open-ended online questionnaire to investigate the common perspectives and perceptions among the Iranian in the current COVID-19 pandemic to provide an acceptable ground to develop and adopt policy recommendations on this pandemic. This study was conducted by the Health Policy Research Center, Shiraz University of Medical Sciences (SUMS), Shiraz, Iran, from February to March 2020.

Sampling and recruitment
Some individuals were selected using snowball and convenient sampling techniques across the country to participate in the present study. In addition, to secure the representation of almost all attitudes, the highest heterogeneity was considered in terms of gender, age, job status, level of education, marital status, and geographical regions. Before mailing the questionnaire's link, an invitation letter containing detailed information about the study (e.g., objectives of the study and anonymity) was submitted to the participants via social media (i.e. WhatsApp, Instagram ...). Further, a written informed form along with the questionnaire was provided to the participants who agreed to participate in the study.

Data collection
In this study, an online questionnaire was used to explore the citizens' expectations from government in the current COVID-19 pandemic. The questionnaire was contain three open-ended question as follow: "What are the main questions of you or those around you about this new virus"?
"What are the main concerns of you or those around you about this new virus"?
"What are the main doubts of you or those around you about this new virus?" According to a pilot investigation, the questions were revised to improve the clarity and content. In addition, an invitation letter and a written consent form including information about research aims and ethical issues, were provided to the individuals. In this process, a population-based random sample of Iranian adults at the age of 18 years or above was recruited via social media (i.e. WhatsApp, Instagram ...) to complete the questionnaire. However, the research team had identi ed one or more focal point in each province to maintain the national status of the study. To this end, the link was sent to anyone who could only answer or send it to anyone else.
The initial questionnaire was delivered to ve experts from academics, all of whom were specialized in the eld of research. During meetings held with them, the validity of the questionnaire, including clarity, comprehensiveness, and the relevance of the questions were examined. After the modi cation of some questions for clarity and content. During the data collection process, the answers were anonymously transcribed and saved in the Windows Microsoft to accelerate the analysis.

Data analysis
The collected data were analyzed and described using thematic content analysis approach. Three of the authors (LZ, AKS, and STH) participated in the analysis process and read and coded the transcribed texts independently to extract the meaning units. Then the detected codes were assessed to detect the subthemes. Finally, the possible connections among the manifested sub-themes were monitored, and the main themes were achieved. During this process, any disagreement between the coders was solved using discussion and consensus strategies. Furthermore, the authors with different scienti c backgrounds and interests participated in the analysis process to foster the critical re exivity in order to reduce the risk of bias [22]. The analysis was performed manually and if required, the analyzers used MAXQDA software version 11 (VERBI GmbH Berlin, Germany).

Ethical approval
Research ethics con rmation was granted by the Research Ethics Committee at the Shiraz University of Medical Sciences (IR.SUMS.REC.1399.090).

Results
In general, 2547 participants agreed to participate in this study and completed the online questionnaire ( Table 1). The Iranian had many expectations from their government regarding its response to COVID-19 pandemic. Because the pandemic had created a kind of despair in the public sphere, the citizens expected serious and effective measures to be adopted by the government. In addition to their personal concerns, they also had serious social concerns. Their social concerns were most concerned with the other citizens' problems caused by this outbreak. The concerns about the further progress of this epidemic in the country on one hand and its effects on losing jobs and the conditions of the poor were among the most frequently mentioned concerns as such the participants presented several expectations in line with these concerns. Three major themes were extracted regarding the citizens' expectations from their government to combat COVID-19 pandemic: (1) Health-related expectations, (2) policy-related expectations, and (3) mass media-related expectations. Further, each major theme had several subthemes, as shown in Table   2. In the following sections, the ndings of the analysis process along with direct quotations from participants' answers are described in details.

Health-related expectations
In this study, a majority of the participants highlighted the need to pay attention to the follow-ups for the infected patients and their family to prevent further transmission. Breaking the transmission chain as well as the provision of nancial and hygiene support during the pandemic was another main expectation. In other words, they believed if the necessary support were not provided to the infected, there would still be a possibility of the virus transmission. In addition, the fair and equitable provision of medical and preventive services to the public, especially the vulnerable groups, was the participants' other demand. As a remarkable nding, the participants described the need for continuous monitoring and screening of the patients' relatives and families to interrupt the transmission chain.
"If the patient is not monitored continuously during the quarantine, the virus may be transmitted to the other individuals." "Households, especially those with patients, should be provided with nancial supports to prevent them from attending outside. On the other hand, more sanitary facilities should be provided to these groups." "Unfortunately, in some cities, the relatives and families of those infected with coronavirus are not concerned as the potential carriers of this virus. I think health centers should monitor them constantly." Providing su cient health supports was another subtheme, which contained a number of codes such as equitable medical care services. Many participants pointed to the unfair access to health care services in Iran and the importance of resolving this problem to facilitate the ght against COVID-19 outbreak. Further, some other participants believed that health packages should be submitted to households by the government and local institutions since, following the economic crisis, many persons cannot afford to buy the necessary personal protective equipment. A number of these individuals also pointed to the poor distribution of preventive measures such as masks and gloves across the country, which led to increased prices, corruption, and di cult access. Accordingly, they proposed the formation of a codi ed and transparent distribution structure by government. For example, they referred to solutions such as the use of the local stores' capacities to distribute aforementioned items and goods. Additionally, the importance of disinfecting the public passages and places were also noted. To sum up, the participants stated that rationale and continuous disinfection was vital according to the researchers' ndings regarding the rapid spread of the virus in public places. More importantly, paying attention to vulnerable groups and appropriately responding to their needs was one of the other common expectations in this study.
"Direct payment for health services is very high in Iran. Although the government stated that the costs of treating the coronavirus patients were to be covered by the insurances, there are still individuals who have confronted with many challenges regarding the transportation and accommodation costs." "It is constantly recommended that people should wear a mask, but there is no mask! Maybe there is, but not available to us. The government must create a proper structure for the distribution of these devices." "Experts have recently stated that the virus would stay in the air for a longer period. I think, the crowded centers should be more disinfected. Although much effort is being made now, they can be more effective." Political-related expectations Our ndings indicated various expectations regarding the political issues. The imposition of strict restrictions, adopting serious monitoring and controlling procedures, and providing nancial support were recognized as the subthemes of this theme. With regard to the adoption of quarantine policies in some countries, the participants called for more serious policies on compulsory quarantine. On the other hand, some of the participants believed that the government had not implemented quarantine policies in a timely manner, and that it would be better if they took actions as soon as possible. Furthermore, another nding was to consider the effective punitive measures for those who do not follow the containment measures. In this study, some of the participants referred to the likelihood for the disease entering from other countries and asked the government to cancel all foreign ights. Since widespread rumors and misinformation are common after crises, serious measures against the rumor mongers would be a potential solution.
"Many people do not pay attention to quarantine and travel. The government must respond this very seriously. I think it should be a mandatory quarantine, like in European countries." "Iran started quarantine too late. From the rst day, home quarantine must have been started so that the disease would not have spread to the other cities." "There are a number of punishments, but they are not enough. Most of these punishments are limited to cars and road transportation. I think individual nes should also be considered for individuals." Many participants expected the authorities to be honest and transparent in providing reports and advice. They argued that honesty could be a proper incentive for citizens to participate and cooperate with the made decisions. Using related experts and experiences from other countries in managing the crisis was the other expectation noted by some individuals. In addition, the participants, regardless of their position, criticized the management of medical centers and believed that the local centers had no su cient authority and autonomy to make quick decisions. Thus, delegating authority to local units might facilitate the process of meeting demands during this pandemic. More notably, a large proportion of the participants identi ed the fair distribution of medical supplies and equipment as well as inter-sectoral cooperation among stakeholders, as a prerequisite for effective response to COVID-19 outbreak.
"Many people have doubts in the sincerity of the authorities. If o cials speak more honestly, people will be more supportive." "We must use the experiences of successful countries such as South Korea and even Germany, which have very low mortality rates." "Crisis management is a purely scienti c and specialized matter and can be achieved by experienced managers. Experts of this eld should be involved as well." "Cooperation and coordination among responsible institutions and also integrated stewardship can be helpful." In accordance with the adverse economic impacts of pandemics such as COVID-19, there were some recommendations to provide nancial supports for the public. The participants noted that bank installments and maturities should be postponed due to the prohibition of commercial activities and a sharp decline in income. Moreover, the non-payment of service bills (water, energy, etc.) and the provision of livelihood packages by the government were also expected by the participants. Furthermore, supplying the low-interest loans to enhance the liquidity for commercial units and the general public during this recession was another expectation.
"Although we have no income, the bank has withdrawn the installments. In this situation, banks should be more considerate." "… especially for poor households, payment of service bills must be canceled or at least postponed." "In this recession, it is possible to facilitate the required liquidity by providing low-interest loans."

Mass media-related expectations
In this study, the participants expressed that adopting honesty and transparency principals by news agencies would promote the social capital. In addition, accurate news and statistics would prevent people from visiting invalid and fake news sources. Many participants believed that there was a need for more comprehensive information about the SARS-CoV-2 transmissions to prevent obsessions and other potential psychological disorders. Finding out how vulnerable groups are affected by the pandemic as well as its side effects were another point stated by the study participants. Remarkably, the participants believed that announcing the related information and statistics by city and location can be effective in informing citizens and adhering to the proposed principles.
"The o cial media must represents the real news to make people more con dent." "If the real news and information is provided, no one will refer to the rumors and fake news." "Elderly people are very worried when it is announced in the news that the disease is more dangerous for this group. More information should be provided on the effects of the disease on the elderly and other high-risk groups." Finally, the provision of comprehensive educational programs was the participants' another expectation from policy-makers in response to COVID-19 pandemic. According to the ndings, proper training in terms of the virus transmission prevention methods, healthy behaviors and how to use e-services were the common expectations. In general, many believed that the general public was not fully aware of the correct preventive methods, and that the capacity of the o cial and virtual media could be further exploited. One of the interesting ndings was the importance of teaching how to change one's lifestyle based on the conditions posed by this pandemic. Certainly, since the implementation of quarantine policies may affect individuals' nutritional and physical conditions, the provision of accurate educational services would prevent many complications.
"The media should provide relevant educational programs tailored to the perceptions of different persons in the community. Many programs use specialized terms not understandable to many people." "Many individuals are not aware of e-services. Relevant training programs can be provided to prevent their direct presence in banks and organizations." "I am very worried about my children's eating habits and physical condition during this period. I wish educational programs were provided so that we could act on them."

Discussion
This study aimed to explore the expectations of the Iranian from the government during COVID-19 pandemic. The detected themes indicate that the citizens have high expectations from their government. It was noticed that people have different expectations regarding the government's response to this pandemic, which encompassed health-related and policy-related expectations as well as mass mediarelated expectations.
Our ndings point to the importance of optimal patient quarantine during boredom and after discharge since the virus is transmitted quickly. In addition, the general public expects support services such as health and nancial services to be submitted to families with the affected so that they can better tackle with the disease. In this regard, after con rming the rst positive cases, a number of countries such as China, France, and Italy implemented highly strict quarantine policies [23][24][25]. However, as Iran was tackling with several economic and social problems at the same time [7,26], it initially focused more on advisory policies and public closures and announced tougher quarantine policies such as prohibiting intercity transportation and shopping malls a few weeks later [5]. In this case, many participants criticized the government's delay. In line with this nding, a rapid review by Nussbaumer-Streit et al. demonstrates that early quarantine has better effects [27]. Given the importance of breaking the virus transmission chain, many participants considered it important to monitor the relatives and family of the infected continuously. Although Iran's Ministry of Health is working on a national screening plan to identify and follow up the suspicious cases before the symptoms appear [5], the in some cities infected come to public places after being discharged and getting recovered, and this is an issue requiring further preventive policies. In line with these ndings, South Korea, as one of the most successful countries in the ght against the disease, has adopted a policy to track the corona virus carriers so that anyone diagnosed with the disease would have an app installed on their mobile phone [28]. In this regard, without disclosing their personal information, their presence in different places is noti ed to the other members of the community [29].
The provision of equitable and affordable health care services was another expectation. Indeed, economic hardships are one of the most important causes of stress, as shown in a study in Bangladesh [30]. Regarding the high cost of health care services in Iran, many people face nancial hardships [31]. In response, Iran's government has also developed a number of policies to increase access to health care services for COVID-19 patients. To this end, the services are completely free for the groups covered by the health insurance, and there are some exemptions for the same group as well [32]. It should be noted that Iran has also provided free health services to immigrants during this pandemic [33]. Continuous disinfection of public places is another expectation to combat the virus transmission. As evidence shows, almost all the affected countries disinfect public places and routes [34]. Our ndings indicate that, despite efforts to disinfect public places, many individuals do not consider them to be su cient and believe that they should be increased in quality and quantity. Additionally, although wearing masks and gloves to prevent infection has been emphasized [6,26], it is still di cult to have access to these protective devices in Iran as such more appropriate production and distribution mechanisms must be adopted. However, the shortage of such equipment after the crisis is not unexpected, as observed in developed countries such as the U.S. and Italy [35,36].
COVID-19 pandemic has been considered as a global political crisis [37]. In Iran, there have been a number of political problems posed by this pandemic. According to the ndings, stricter enforcement measures during the quarantine period and the imposition of effective nes were expected by the participants. From another perspective, many participants stated that travel from cities such as Qom and Tehran, as the sources of the outbreak, should be prohibited, as in Wuhan [25]. However, given the limitations of Iran's government and international sanctions, such a strategy has not been possible in practice [7]. Many participants also called for serious actions against lawbreakers and rumor mongers, as an effective approach in facilitating the ght against COVID-19. Evidence suggests that countries such as India and France have imposed severe penalties on lawbreakers, with the aim of slowing down the spread of the virus [38,39]. In addition, Saudi Arabia, based on its experiences with MERS pandemic, imposed heavy nes on violators during COVID-19 outbreak [40].
Honesty and transparency are the best policies in the crisis management [41]. As evidence indicates, openness and honesty can promote the ght against the pandemic, as observed in the case of SARS in 2003 in Hong Kong and Taiwan [42,43]. Moreover, the participants emphasized the importance of the authorities' honesty and expressed it as a requirement for public trust. Further, the ndings indicated the need for greater use of experts in COVID-19 control process in Iran. On the other hand, since coordination and collaboration among stakeholders and actors is a crucial prerequisite for effective policy-making and implementation of programs and strategies [44], a majority of the participants also highlighted this point. Further, the need to delegate authority to relevant local institutions and centers to expedite the decisionmaking process was another nding of this study. Unfortunately, the existence of slow bureaucratic structures in Iran has always been considered as one of the obstacles in the face of crises [45]. Notably, Norway was one of the most successful countries in controlling the COVID-19 using the capacity of regional and local enterprises such as municipalities [46]. Furthermore, due to the delegation of strong power to local organizations in Japan, local governments in Tokyo and Hokkaido responded to the COVID-19 outbreak earlier than the national government [47].
The negative economic effects of pandemics have always been a major challenge to societies [48,49]. Speci cally, during a short period after the COVID-19 outbreak, the world economy faced many problems; hence, the citizens, especially the vulnerable, have a range of expectations from their governments [50].
Based on our ndings, the participants declared that, with regard to the economic problems, delaying the bank installments, providing low-interest loans, submitting livelihood packages to poor households, and considering exemptions from non-payment of service bills could be potential policies. Different countries have pursued different nancial policies in the face of the disease. For example, South Korea allocates approximately $1030 per month on a family of four with an infected patient [51]. Similar policies have been adopted by Italy, the United States, Germany, Japan and France [52]. Furthermore, the British government has set aside about $400 billion to support small and large businesses in the form of guaranteed loans [52]. In addition, the Swiss central bank called on its banks to refrain from paying dividends and repurchasing stocks as the government seeks to increase funding to prevent the industry stagnation. The Swedish Financial Supervisory Authority has also announced that it has given banks the permission to defer the re-payment of mortgage installments [53]. Therefore, since the International Monetary Fund forecasts a negative 3% global growth in 2020 [54], various countries, including Iran, need to develop comprehensive policies to reduce the negative economic effects of COVID-19 pandemic.
Experts believe that the main role of the media in crises such as pandemics is to publish the right news, reduce the pessimism towards the information and news of o cial sources, and also create peace of mind [55][56][57]. In the present study, the participants demanded for provision of real time and accurate news and statistics by the o cial media, and many believed that people's distrust had turned them to uno cial sources. In addition, mass media play a signi cant role during pandemics such as effective health communication for consideration of the preventive measures, appropriate approaches for helping individuals in dealing with the social distancing, and reduction of inequalities, stigma, and psychological disorders [58]. In other words, media are acknowledged as a main tool in risk communication during this situation; however, the impacts of media on the pandemics are complex [59]. To sum up, considering the importance of mass media and their potential bene ts can be an appropriate solution to reduce the adverse effects of COVID-19 epidemic.
We believe that in this pandemic, especially in the rst wave, the government confronted a serious challenge from the citizens. Part of it goes back to the historical and cultural context of the governmentcitizens relationship. In this view, the relationship between the government and citizens was not based on trust; also, social capital was low. Such a condition dominated the mentioned relationship during the rst wave of the epidemic. This general mentality was highlighted during the rst wave because, according to citizens, Iran would face an epidemic due to weak sovereignty, resulting in severe mortalities. The main causes of such a situation were these: failure to close air borders with China, due to political considerations, and also the inability, due to religious considerations, to quarantine Qom, the most prominent religious city in which the rst cases of COVID-19 were identi ed. This discourse was then starkly highlighted by Iranian opposition media and was widely circulated in cyberspace. In the rst wave, this issue exerted a great amount of pressure on the government and undermined the little trust citizens had in the government. However, when developed countries such as Spain and Italy, and then the United States were severely affected by the epidemic, the pressure of this discourse was drastically reduced. This indicates that the relationship between the government and citizens and their expectations of the government are formed and changed in historical and cultural contexts as well as temporal and spatial conditions in outbreaks.

Limitations
Three most important limitations of the current work should be mentioned before generalizing the ndings. First, the current study did not conduct the conventional quantitative methods and the data collected through textual information online rather than quantitative data. Second, it is a cross-sectional study so that we can't capture the changes in perspectives/ perceptions in accordance with changes in the COVID-19 epidemic. Finally, because our study was online the most important limitation is access to the internet. Certain populations, like rural, low socio-economics, or disadvantaged groups, are less likely to have internet access and to respond to online questionnaires.

Conclusions
In total, three main themes (namely health-related expectations, policy-related expectations, and mass media-related expectations) were recognized as the main expectations from government to ght COVID-19 pandemic. Our ndings show that people face a number of challenges during this pandemic, and they thus expect the government and other responsible institutions to minimize their burden by adopting effective policies. Further, the ndings of this study could help the decision-and policy-makers to become aware of people's expectations and develop better strategies. It is suggested that governments be aware of the needs of their citizens in the epidemics and adjust their policies accordingly. Quantitative studies in this subject are also recommended. The data collected and analyzed during the study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.