The common concerns regarding the COVID-19 outbreak in Iran: Explored ndings from a qualitative study

The rst cases of coronavirus disease 2019 (COVID-19) were reported in Iran on February 20, and then the virus spread rapidly in all parts of the country, so that over 95000 positive cases and approximately 6000 deaths have been conrmed in this region until May 1, 2020. Even if measures taken in this respect have had signicant impacts on reducing the incidence rate of COVID-19, a large number of other problems have arisen. Following this situation, people have been also drawn against many concerns, especially Iranian population with their own previous socioeconomic and cultural problems. Therefore, this nation-wide project aimed to investigate common concerns regarding COVID-19 outbreak in Iran. Methods This study


Abstract Background
The rst cases of coronavirus disease 2019  were reported in Iran on February 20, and then the virus spread rapidly in all parts of the country, so that over 95000 positive cases and approximately 6000 deaths have been con rmed in this region until May 1, 2020. Even if measures taken in this respect have had signi cant impacts on reducing the incidence rate of COVID-19, a large number of other problems have arisen. Following this situation, people have been also drawn against many concerns, especially Iranian population with their own previous socioeconomic and cultural problems. Therefore, this nationwide project aimed to investigate common concerns regarding COVID-19 outbreak in Iran.

Methods
This qualitative study was conducted in Iran from February to March 2020 via an online open-ended questionnaire. The participants were also selected using convenience and snowball sampling methods.
As well, the data collection process continued until data saturation was achieved. In addition, thematic content analysis was utilized to analysis the transcribed texts.

Results
The statements retrieved also represented the most challenging psychological stress experienced by the participants. Four themes were accordingly recognized based on the content analysis including stressful conditions, health concerns, social and political concerns, and economic concerns. Throughout the study, a major proportion of the participants commented that psychological disorders such as fear, anxiety, stress, and ennui were their main challenges regarding this pandemic. Furthermore, lack of social responsibility, worries about high-risk and susceptible groups, decreased economic power of the public, nancial hardships for low-income groups, shortage of healthcare facilities, and adverse effects of disinfectants were expressed as the main concerns.

Conclusions
As a whole, it is evident that people have confronted with several challenges and need help together with effective policies and strategies during and after this pandemic to reduce their current concerns. The study ndings provided a favorable ground to develop and adopt the required policies in Iran and other countries. It was concluded that creating local, national, and global solidarity in such epidemics is an inevitable necessity. Background Page 3/22 Following several reports on an unknown virus in December 2019 in the city of Wuhan, China, a novel coronavirus (namely, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)), was discovered on January 6, 2020 [1]. By 27 April 2020, more than three-million con rmed coronavirus disease 2019 (COVID- 19) cases have been detected in almost all parts of the world. Nearly 240000 infected cases have unfortunately died until this date [2]. As a rapidly growing pandemic, however, a major concern is its fast and easy spread [3]. Therefore, various measures such as isolation of infected cases, limitation of contacts, travel restrictions, promotion of proper personal hygiene, as well as use of masks and gloves have been adopted by governments and citizens to lower transmission rates [4].
On February 20, the rst COVID-19 cases were reported in Iran, and then the virus spread rapidly throughout the country, so that over 95000 positive cases and approximately 6000 deaths have been reported in this region until May 1, 2020 [2,5]. Several policies and strategies have been correspondingly adopted to prevent and control the spread of COVID-19 by the government such as social distancing and business closure [6]. Although these measures have had considerable impacts on reducing the incidence rate of COVID-19, a number of problems have arisen [7]. Indeed, job losses and nancial concerns have been usually among the rst knock-on effects of pandemics [8]. In addition, due to the sharp increase in positive cases, both public servants and medical staff have been subjected to psychological disorders including depression and anxiety [9].
As reported, the negative economic effects of COVID-19 have been signi cant [4].. For instance, over 6 million people have registered for unemployment insurance in the United States since one month ago [10]. Additionally, the United Nations (UN) has demonstrated the catastrophic impacts of this pandemic on economies of developing countries [4]. Speci cally, based on the related literature, nearly 65% of economic activities have been reduced in manufacturing and service sectors in Iran following COVID-19 outbreak [11]. Fall in oil prices is on other challenge for Iran's economy, which will cause a severe government budget de cit [5]. Behind these economic shocks, a major proportion of population has confronted with the deaths of family and friends as well as physical consequences of this pandemic [12].
On the other hand, social lockdown and self-isolation can lead to the occurrence of high-risk behaviors such as alcohol abuse or even increasing incidents of domestic and family violence [13].
Following this situation, people have faced many concerns, especially Iranian population with a large number of previous socioeconomic and cultural problems [5]. Therefore, comprehensive identi cation of these concerns can provide a favorable ground in order to develop and adopt effective policies and strategies, interventions, and guideline documents to ght COVID-19 and to alleviate its adverse effects. For this purpose, this nation-wide project was conducted to investigate common concerns regarding COVID-19 outbreak in Iran.

Methods
The present study was part of a larger survey project conducted at Health Policy Research Center (HPRC), Institute of Health, Shiraz University of Medical Sciences (SUMS), Iran, conducted from February to March 2020. Thematic content analysis was also employed to investigate common concerns of Iranian people regarding COVID-19 outbreak. The protocol of this project had been previously con rmed by the Institutional Review Board (IRB) of SUMS.

Participants
The participants were selected using convenience and snowball sampling methods at a national level. To this end, the research team strived to select individuals representing maximum variation in terms of age, gender, employment status, marital status, level of education, and geographic location. As well, the data collection process continued until data saturation was achieved. Although there was no valid evidence, 150 responses with duplicate data were considered to con rm the saturation. Prior to sending the openended online questionnaire, a written consent form and an invitation letter including information about research objectives and related ethical principles, were given to the participants via WhatsApp and Telegram as the top social messaging applications used in Iran. Furthermore, additional information was provided by the research team to these individuals if requested.

Data collection
An online questionnaire including open-ended items was utilized to investigate common concerns among Iranian people regarding COVID-19 pandemic. In this questionnaire, the participants were asked to express and write their concerns and experiences. Based on the provided feedback from initial responses, the format of the items was modi ed for further clarity. After receiving responses, the transcribed texts were simultaneously organized and saved by the rst author (a male PhD Health Policy) in the Microsoft O ce software to facilitate the analysis process.

Data analysis
The collected data were analyzed using thematic content analysis. Inductive approach was further considered to grasp latent and obvious content. The approach developed by Braun and Clarke consisting of six steps including (1) familiarizing with collected data, (2) establishing initial codes, (3) identifying primary themes, (4) evaluating emerged themes, (5) labeling identi ed themes, and (6) reporting results, was used to analysis the collected data [14].

Rigor and trustworthiness
There are a series of techniques to upgrade rigor and trustworthiness of qualitative studies. Credibility (i.e., credible interpretation of data), con rmability (that is, truthfulness of ndings), transferability (namely, degree of applications of ndings in other contexts), dependability (viz. repeatability and soundness of ndings), and authenticity (meaning, faithfulness of authors in describing realities) are thus determined as the main criteria of trustworthiness [15]. According to the approach proposed by Guba and Lincoln, several techniques can be utilized to ensure the suggested criteria including member checking by co-authors (con rmability), considering a large sample size (transferability), peer debrie ng and data triangulation (credibility), participation of four authors in data analysis process (dependability), and use of citations from various participants (authenticity) [16]. For this reason, the analysis process was performed in parallel with data collection in this study. Four authors were also involved in this process, reading and re-reading the transcribed texts independently. Then, meaning units were recognized as the initial codes. The established codes were subsequently monitored by two authors, and similar codes were reduced to sub-themes. Finally, the potential relationships among the emerged sub-themes were assessed, and the nal themes were established. Discussions and consensus strategies were also used to solve any disagreements among authors during the analysis process. The analysis was performed manually, and if required, the MAXQDA 11 software package (VERBI GmbH Berlin, Germany) was employed. To diminish the potential risk of bias in this qualitative study, critical re ectivity was implemented as one of the various methods suggested for this purpose. To ensure this strategy, authors with different backgrounds and scienti c experiences were participated in data analysis process.
The standards for reporting qualitative research (SRQR) [17] and the consolidated criteria for reporting qualitative studies (COREQ) [18] (supplementary le 1) were additionally considered to con rm all parts of this qualitative study.

Ethical approval
The Ethics Review Committee of the SUMS (IR.SUMS.REC.1399.090) approved the study and all individuals gave informed consent form.

Results
In total, 2547 individuals agreed to participate and completed the questionnaire (Table 1). Figure 1 summarize the recruiting process. The data analysis in this study showed that all the participants were living with chronic stress and anxiety. The responses implied a form of individual and social uncertainty about COVID-19. There was also social anxiety and fear because of this pandemic. Concerns about disease transmission, as well as worries about social and economic affairs, were the most pronounced ones by the participants. Four themes were ultimately recognized through the content analysis including stressful conditions, health concerns, social and political concerns, and economic concerns. Each theme also had sub-themes containing a number of assigned codes ( Table 2). In what follows, detailed ndings accompanied by quotes from the participants' responses translated from Persian have been presented.

Stressful Conditions
The retrieved statements revealed stressful conditions lled with fear and social anxiety. In this respect, a major part of the participants commented that psychological disorders such as fear, anxiety, stress, and ennui were their main challenges regarding COVID-19 pandemic. Indeed, they believed that a signi cant degree of worry, fear, and concern especially among certain groups such as disabled people, older adults, healthcare providers, and patients with underlying health conditions had emerged as the virus was rapidly spreading across the country. For example, some participants stated that: "I think, these days, a very bad atmosphere has been created. We always feel stressed-out about everything"[0024] "Frankly speaking, I am not worried about myself at all. I am really concerned about older people in the family who might get sick during this pandemic"[0057] "My wife is exceedingly sensitive and disinfects everything and everywhere so much that, I think, she is hurting her respiratory system"[0146] Fear of an uncertain future was another sub-theme comprised of several codes such as disruptions in personal programs. Some participants also claimed that this pandemic has interrupted their prede ned appointments and plans. Furthermore, uncertainty about the future of their jobs and employment status was expressed by most of the participants. Some individuals, especially students, additionally aired their concerns regarding the future of their academic education. For instance, one of the participants asserted that: "As a Master's student, I am very confused. Virtual training does not really exist. The due time for starting university courses has not been announced yet. So, we have to wait and kill time!"[0291] Health concerns Health and hygiene issues were explained by a majority of the participants. Mysterious and unknown virus, lack of healthcare facilities, and adverse effects of disinfectants were thus identi ed as the main sub-themes in this category. The participants also reiterated that the virus had caused stress since it was unknown. Furthermore, the rapid spread of the virus had been considered as a potential factor inducing such worries. As a whole, uncertainty about routes of virus transmission, unknowing carriers, long incubation period of the disease, and lack of the same symptoms in patients were among other concerns. In this line, some participants added that: "The virus is very mysterious. It is not clear how it is transmitted. This has made us feel down"[0065] "As doctors say, the disease spreads very quickly. So, we are very worried that we will be infected soon" [0098] "For the reason that some patients do not have symptoms, we are obsessed with everyone"[0401] A large group of the participants in this project described COVID-19 as a terrible phenomenon. They further noted that they were always afraid of becoming infected due to the rapid transmission of the virus. On the other hand, fear of being a virus carrier was a common concern, which was detected all through the study. Many people were also concerned that they might be carriers of the virus and pass it on to their relatives and other people around them, especially vulnerable groups. As a notable conclusion, some participants pointed out the fear of death from COVID-19 and its unpleasant burials. As examples, some participants said that: "I am always afraid of getting infected. When I come home, I disinfect all my clothes and belongings. But I am still pessimistic about this virus"[0563] "I am dreadfully worried about transmitting the virus to others, especially my children or parents. If this happens, I will suffer a pang of conscience"[0057] "The process of burying the dead is very painful. Even the closest people cannot attend the funeral. I do not like to die like this at all"[0126] Furthermore, concerns regarding high-risk and susceptible groups were another category emerged from the data. Based on this category, fear of making others around like women, children, elderly people, healthcare providers, and bank employees sick, were repeated in almost all responses. In this vein, some participants maintained that: "I am more concerned about pregnant women, children, and the elderly, who are more likely to be at risk if they become infected with this virus"[0067] "My husband is a bank employee. Banks must be open according to the announced protocol in Iran. Given the deaths of several bank employees across the country, I have extreme stress that something bad will happen to him"[0186] Regardless of these ndings, almost all the participants criticized the policies and strategies adopted by the government and other authorities. In fact, they argued that there was an inconsistency between institutions and actors and even no clear responsibilities. For instance, some participants' responses were as follows: "It is very unreasonable that the Ministry of Health and Medical Education says one thing, the Ministry of Industry declares one thing, and at the end of the night, Mr. President criticizes everyone" [1603] "Although a national anti-corona headquarters has been established, the responsibilities are not very clear for the public"[0445] "I do not think the government has managed things very well. In my opinion, the government could have taken precautionary measures much sooner" [1291] In addition to shortage of healthcare facilities as a major factor raising concerns regarding this pandemic in Iran, the participants illustrated several other challenges such as inadequate hospital capacity, absence of specialists, unavailability of sanitary and preventive equipment, lack of medications and vaccines, as well as hoarding of sanitary goods throughout the study. As examples, some participants stated that: "The hospital located in my hometown does not have enough capacity at all. So, if we get sick, where do they take care of us? " [2221] "My serious concern is lack of specialists and medical staff in many remote cities"[1007] "Sanitary and preventative equipment such as masks and gloves are not available. They are also very expensive" [1905] Ultimately, many participants mentioned the adverse effects of disinfectants. For instance, most participants reported their concerns regarding the negative impacts of alcohol use on their respiratory systems as well as other organs. In addition, many women expressed concerns about the adverse effects of bleach cleaners, which are widely used for disinfection. Since hand washing had been introduced as one of the initial strategies to prevent the virus transmission, a large group of the participants described a kind of concerns regarding their skin conditions. In this line, some participants said that: "Many of our citizens have lost their lives due to alcohol abuse. We are very concerned about the misuse of disinfectants, especially by children."[0508] "Use of disinfectants has caused all family members cough. Now, we have the stress of getting sick"[0754] "I wash my hands a lot. My skin is damaged. I do not know if it will be cured or not!"[0992]

Social and Political Concerns
In this category, a number of challenges and concerns were expressed throughout the present study. The participants suggested lack of social responsibility as one of the main concerns. No understanding of the seriousness of this crisis, non-compliance with quarantine, gathering in stores, travels, and inattention to warnings were among the considerable results. For example, some participants asserted that: "Many people do not take the disease seriously, especially at its onset. When you go out, you can see many people there"[0035] "In our city, majority of citizens do not pay attention to quarantine and social distancing. They go to other cities very easily. In any way, they can do it"[0047] "I saw a clip from one of the shopping malls on the night before Nowruz (i.e., Persian New Year). The shopping centered was very crowded. I think one infected person is enough to make other sick"[0391] "On the last day of the year, the tra c on the Tehran-Qom highway was terrible. There is a lot of traveling without paying attention to this pandemic"[0622]

Economic Concerns
The participants mentioned the negative impacts of COVID-19 pandemic in the short and long term. In this respect, some participants said that: "After this pandemic, quarantine policies have disrupted many of my career plans. Someone like me who has bank debts has to work to make money. If I do not work, I will be in the red."[0065] "I am very saddened by Iran's economic future. We had negative economic growth last year and even high in ation rate. Now that this situation has arisen, the economic situation will de nitely get worse. We may lose our jobs" [0429] Most of the participants believed that the adopted policies in Iran such as social distancing had signi cant nancial hardships for low-income groups. Accordingly, daily-wage workers, street children, and beggars were introduced as the most susceptible groups following this situation. As examples, some responses provided by the participants were as follows: "The economic burdens of this disease are very heavy, especially in Iran, which has already suffered from many other economic problems" [1274] "I know a lot of people who have a daily income, but now they have no take-home pay" [2106] The ndings from the content analysis indicated an increase in the prices of basic goods across Iran.
Many people additionally cited higher in ation rate, fall in oil prices, and devaluation of the national currency as short-term effects of this pandemic, which could cause many other problems. In addition, weak healthcare insurance coverage as one of the main challenges of Iran's healthcare system could confront households with catastrophic expenditures. Therefore, majority of the participants had faced high rate of out-of-pocket pays regarding COVID-19. Besides, information about the rising costs of sanitary and preventive equipment was declared by these individuals several times. In this line, some participants reiterated that: "After COVID-19, food staples like rice have become very expensive. On the other hand, fall in world oil prices has reduced the value of the national currency. I think this makes things much more di cult"[0884] "Many patients have to pay a large part of the costs themselves. Heavy nancial burdens are also imposed on households. Our healthcare insurance system is not very effective" [1308] "The high costs of sanitary and preventative equipment such as masks have made everything very di cult. The price of masks has increased by tenfold"[0052] Decreased economic power of the public was another big concern identi ed in this study. In this regard, the participants had experienced that a large part of Iran's population had lost their incomes, especially self-employed ones. In addition, COVID-19 pandemic had resulted in business closure and job losses, which could be a source of many other concerns. For instance, some participants added that:

Discussion
Four themes and a broad spectrum of sub-themes and codes were identi ed in the present study. Accordingly, the ndings highlighted common concerns of Iranian people regarding COVID-19 outbreak.
The main ndings of this study re ected on widespread psychological concerns following COVID-19 pandemic in Iran. Indeed, this situation was considered as an unprecedented period for all people, especially for children confronting a massive disruption in their daily living [19]. However, being at home might expose all household members to increased risks. Domestic and family violence has been similarly reported as a common high-risk behavior after home quarantine in parts of the world [20]. For instance, such violence has respectively risen by nearly 25-60% in the United Kingdom and Mexico since government policies have merely focused on controlling the disease progression [21,22]. In this situation, vulnerable groups such as children and older adults might be more affected [23]. Regarding these abuses, countries like France have developed policies to help the victims. As the movement of the citizens has been restricted, France has been advising female victims to seek help at drugstores using code words [24]. Findings had also indicated the fear of an uncertain future as the negative impact of this pandemic. Based on the evidence, this fear could stop the population from ful lling their duties very well, and it could even retain many people holding onto situations hurting them [25]. Therefore, decision-makers and policy-makers should develop effective and community-based policies and strategies to reduce individual concerns in these stressful conditions following COVID-19.
In this study, lack of social responsibility was identi ed as one of the main social concerns. Although public education was being conducted through the Islamic Republic of Iran Broadcasting (IRIB) and the mass media following COVID-19 pandemic, some groups resisting such recommendations. Experts also believed that having a single voice in the society could increase social responsibility [26,27]. Another part of concerns was in terms of dealing with vulnerable groups such as pregnant women, children, older people, and healthcare providers. The ndings additionally showed that a large proportion of the population was worried about the risk of exposure to COVID-19 in these vulnerable groups. Concerns about the infection affecting pregnant women and children also fueled after the con rmation of the birth of a newborn child in China [28]. Nonetheless, the World Health Organization [29] revealed no evidence that pregnant women are at higher risk of severe COVID-19 in a population [4]. In accordance with the literature, verbal and emotional support could signi cantly reduce such concerns [30].
Moreover, concerns about incompetence and dishonesty of authorities were one other social and political challenge addressed throughout the study. The occurrence of political and social events in recent years, and especially in the last year, in Iran, could be effective in such situations. On the other hand, the weakness of social capital in this country had a long history [31]. Several studies have correspondingly revealed the importance of social capital in pandemic periods [32][33][34]. For instance, generalized and institutional trust in healthcare provision was considered as a potential factor in uencing the acceptance of health-protective behaviors in Sweden following the 2009 swine u pandemic (H1N1) [32]. Therefore, using effective solutions to promote the credibility of the government and community-based networks might positively affect prevention and control of COVID-19 pandemic in Iran.
Short-and long-term adverse effects of this pandemic on Iranian economy were among common concerns underscored by the participants. In fact, pandemics are accompanied by considerable economic disruptions although they are rare [35,36]. Based on the WHO report [37], pandemics such as avian in uenza could lead to signi cant economic losses e.g. the H1N1 and severe acute respiratory syndrome (SARS) pandemics have had signi cantly negative impacts on national and global economies [38][39][40].
Following these trends, a major proportion of society, especially low-income groups, had been confronted with nancial hardships, as mentioned in the study. Furthermore, rising in ation and unemployment rates as other impacts of economic recession following the pandemic could result in severe concerns and anxieties across the country [41]. Therefore, developing and adopting economic policies at macro-and micro-level to control the adverse effects of COVID-19 pandemic fairly and immediately is an inevitable necessity. In addition, sanctions have worsened the situation for Iranians facing the virus [5]. There is thus a need for global solidarity in such epidemics and even acting against unfair sanctions.
The special feature of new COVID-19 is that it is unknown and mysterious [6]. The participants pointed out this feature as the origin of a number of concerns. Indeed, lack of clarity about the source of the virus, as well as its modes of transmission, had created tensions and obsessions for society. In addition, following this pandemic as well as a sharp growth in the number of new positive cases, shortage of sanitary and preventive equipment in Iran, as in most affected areas, have raised concerns in the public. Furthermore, COVID-19 similar to other previous pandemics such as SARS has no de nite treatment and its incubation period has left people in a state of ambiguity [42]. More importantly, overuse of alcohol and bleach cleaners as disinfectants has resulted in mild respiratory disorders for Iranian people, so that many people expressed concerns about the side effects of these substances on their health status [43]. Therefore, informing the public about the common ways the virus spreads from person to person, how to prevent it, and how to use disinfectants to prevent or at least moderate these concerns can be among effective strategies in this respect.

Conclusions
As a whole, four main themes i.e., stressful conditions, health concerns, social and political concerns, and economic concerns were identi ed as the common concerns about COVID-19 outbreak in Iran. It is evident that people have confronted with several challenges and need help with regard to effective policies and strategies during and after the pandemic to minimize their current concerns. The study ndings also provided a favorable ground to develop and adopt the required policies in Iran and other countries. In this situation, human beings need some kind of solidarity at local, national, and international levels.
Abbreviations SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; UN: United Nations; IRB: Institution Review Board; SUMS: Shiraz University of Medical Sciences; WHO: World Health Organization; SARS: severe acute respiratory syndrome.