Stress and anxiety resulting from COVID-19 in the Iranian population – a questionnaire-based study

The COVID-19 disease, which has come to be known as Corona, is a new virus from the generation of coronaviruses. The aim of this study was investigated the stress and anxiety caused by COVID-19 among the Iranian population. Method and materials This is a cross-sectional and descriptive –analytical study with the available (easy) sampling method over the period of July 2020 to Jan 2021 on the Iranian population using a questionnaire. A researcher-made questionnaire was used. The data collection tool of this study was a questionnaire containing demographic information (age, gender, and marital status), general questions and questions related to the stress of COVID-19. The collected information were analyzed using t- test, chi2 and the SPSS21 software. In the present study, lled 3456 of the respondents were female and the remaining 3078 were male. The average age of participants was 39.41 ± 12.4. The results of this study showed that 98.2% (No: 6425) of the individuals agreed that their stress was related to this natural disease. The results showed that the stress caused by corona has the most signicant impact on the social aspect and then on the physical behaviors of the patients. The present study showed that the average score obtained from the questionnaire was 97.2 ± 15.3 out of 130 which was an indication of high levels of stress caused by this disease. There was a signicant relationship between the scores associated with gender(P = 0.001), job(P = 0.01), one’s infection(P = 0.001) and one’s family’s viral infection(P = 0.02).


Introduction
The Corona viruses are a large group of viruses that infect animals and humans and cause respiratory problems and distresses; which could be as mild as a cold or as severe as a pneumonia. In rare cases, The COVID-19 disease, which has come to be known as Corona, is a new virus from the generation of coronaviruses. On the 31st of December of 2019, the World Health Organization (WHO) discovered some reports on a cluster of viral pneumonia with unknown causes in Wuhan, Hubei and investigation began in early January of 2020. On the 30th of January, WHO announced the outbreak of a global public health emergency as an international concern(2, 3).
There is no de nitive cure for this disease to date and the medical knowledge and information about it is still very little. This epidemic has caused global economic and social disorders. The news of the diseases and causalities caused by this virus, along with the fact that many people might be a carrier of this virus for two weeks or even more, without knowing it, in addition to the inaccurate information that is shared on social media and collective media about the virus, the level of stress and fear people experience when facing this virus is quite high (4,5,6).
Despite continuous efforts on the part of researchers all over the world, to this date, a vaccine or antiviral drug has yet to be provided for COVID-19 infections which would be clinically effective on human beings. In addition, lack of a certain treatment or prevention method has caused societies to be quite stressed and worried. The fear and anxiety caused by the probable infection have created a great deal of damaging mental load which can lead to mental and spiritual abnormalities, weaken the immune system and reduce the body's ability to ght illnesses in members of the society. The most stress is caused because an individual feels that their own life, their future as well as the lives of their loved ones and families are in danger. However, stress is the emotion that keeps humans away from harmful situations.
If the stress caused by COVID-19 makes individuals observe individual hygiene and health, to avoid getting together with other people and forming communities and to observe house quarantine, this stress will be quite useful and constructive; only if it does not exceed logical behaviors and does not get damaging and disorder-like (8, 7).
Based on the announcement of WHO, from December of 2019 to May of 2020, in more than 490 countries of the world, around 6,299,019 new cases and 112,966 deaths were reported. During the same period of time, in Iran, the number of new cases was 416,661 and the number of deaths was 6000 new cases. Russia, Brazil and USA were the countries with the highest number of cases. In the January of 2020, WHO declared the COVID-19 epidemic to be a public health emergency of international concern.
Based on the global statistics, the mortality rate of 3.4% has been recorded for this disease (9). In Iran, the rst con rmed case of infection was on February 19th in Qom. According to the ministry of health and medical education, two people lost their lives that day (10). The present study has aimed to investigate the stress and anxiety caused by COVID-19 among the Iranian population.

Method And Materials
This is a cross-sectional and descriptive -analytical study with the available (easy) sampling method over the period of July 2020 to Jan 2021 on the Iranian population using a questionnaire. The criteria for entering this study was 18 or higher year of age, literacy or the ability to read and write, expressing informed verbal consent and not being in a critical situation (such as divorce, loss of a loved one, illness or hospitalization experienced by themselves or their immediate family and loved ones). Individuals who entered the study were reassured that in case they were willing to ll out the questionnaire, their information would remain con dential and it is merely meant for statistical analysis. A researcher-made questionnaire was used and in order to con rm its validity, it was given to three psychiatrists and a statistics specialist who con rmed the validity of the questionnaire. In addition, to test the reliability of the questionnaire, it was given to 20 of the members of the research population within ten days. It was proved that this questionnaire was properly reliable (coe cient of Cronbach's alpha = 0.85).
By taking the conditions of each individual into consideration, su cient time was considered for lling out the questionnaire. The data collection tool of this study was a questionnaire containing demographic information (age, gender, and marital status), general questions and questions related to the stress of COVID-19. The questions were scored based on the Likert scale (scaling from totally agree with the score 5 to totally disagree with the score 1). Thus, the score obtained for this questionnaire was between 26 and 130. The collected information were analyzed using t-test, chi 2 and the SPSS21 software.

Results
In the present study, 6752 questionnaires were distributed, 6534 of which were lled out. 3456 of the respondents were female and the remaining 3078 were male. The average age of participants was 39.41 ± 12.4. Most individuals were freelancers or employed workers. Most of the respondents had an associate degree and then a diploma. This study shows that 5.7% of the respondents had been infected by the corona virus, and 12.4% of the respondents have had one of their family members dealing with the infection. In addition, 24.9% of the respondents considered themselves to be an anxious person. Table 2  The results of this study showed that 98.2% (No: 6425) of the individuals agreed that their stress was related to this natural disease. The present study showed that highest levels of stress was associated with this viral infection and the second highest level was associated with the family member's viral infection.
The results showed that the stress caused by corona has the most signi cant impact on the social aspect and then on the physical behaviors of the patients. In such a way that the stress caused by this viral infection increases one's heart rate and causes sleeping problems. In addition, as far as the social aspect is concerned, because of COVID-19, individuals did not visit the dentist as much and were worried about losing their teeth too. The effect of corona on one's job, education and even daily workouts were other factors that caused stress. Table 3  The present study showed that the average score obtained from the questionnaire was 97.2 ± 15.3 out of 130 which was an indication of high levels of stress caused by this disease. There was a signi cant relationship between the scores associated with gender(P = 0.001), job(P = 0.01), one's infection(P = 0.001) and one's family's viral infection(P = 0.02).
By comparing the score of stress based on the age variable, it was shown that there was a higher level of stress in the age group of 30 to 40 years and 50 to 60 years which is statistically signi cant(P = 0.001). In addition, the level of stress was higher in female respondents than male ones(P = 0.001), in employed respondents than in those without a job (0.001), in married respondents than single respondents(P = 0.03). Table 4

Discussion
Fear and anxiety caused by the possibility of infection are quite harmful and damaging and can cause mental -spiritual abnormalities and disorders as well as stress. The fear and stress are created through the stimulation of hypothalamus in the brain and the increased secretion of cortisol from the adrenal cortex and stimulation of the sympathic nerves throughout the whole body in the short term for the body to overcome stressful factors. However, if this fear and stress and body's response, i.e. increased level of cortisol and sympathic stimulation, remains in the body in the long run, it would be harmful and damaging, weakens the immune system and reduces body's ability to ght diseases such as corona. Therefore, coping with stress makes the society more resistance to illnesses (6, 11, 12).
When one faces severe and long-term stress and is not able to manage this stress, due to the severe and long-term increase of the cortisol hormone in the body, they would face issues such as sleep disorders, obesity, decreased tolerance threshold and weakened performance of the defensive system (13).
Clinical observations and studies have shown that during this pandemic, many people have dealt with the stress associated with the fear of being infected, touching different surfaces and objects that might be infected, and the fear of social -economical consequences caused by the pandemic (14).
Stress can weaken the body's immune system and make it vulnerable to diseases such as the corona virus. In such cases, the elderly and the people suffering from chronic diseases are more likely to be affected by COVID-19 and the stress caused by it. Children and teenagers, individuals that help others due to their responsibilities (such as doctors and other caretakers or social workers) and individuals who consume drugs due to certain mental health conditions experience more stress. According to the ndings of previous studies conducted at the time of spread of the SARS and the Ebola, psychological disorders such as anxiety, stress and depression were reported to be highly prevalent (15).
This study showed that those under study have had high levels of stress. Also, there was a signi cant relationship between the scores associated with gender, job, one's infection and one's family's viral infection. By comparing the score of stress based on the age variable, it was shown that there was a higher level of stress in the age group of 30 to 40 years and 50 to 60 years which is statistically signi cant. In addition, the level of stress was higher in female respondents than male ones, in employed respondents than in those without a job, in married respondents than single respondents.
With The ndings of the present study showed that the scores associated with stress were higher in women than men. The study conducted by Li et al. (21) showed that women report a higher level of stress and anxiety related to COVID-19. Gerhold et al. (22) conducted a study in Germany and concluded that women were more worried about COVID-19 than men.
According to the ndings of Bakioğlu et al. (23) the fear of COVID-19 was signi cantly higher in women than in men and it is also higher in individuals suffering from chronic illnesses in comparison with those that do not suffer from any chronic illness.
Gender-related differences in association with the fear caused by COVID-19 comply with this nding that the coronavirus pandemic causes more mental effects in women, which is compatible with the ndings of previous studies about the mental health of women (24).
Gender is a factor that affects the health of individuals (25). In general, women deal with pressures caused by the environment much better; nonetheless, they are usually physically weaker and get sick easier (26). Another factor that might be effective in this regard is that women are more vulnerable, weaker, and more delicate and culturally, it is easier for them to voice their complaints and fears about the illness. On the other hand, the role of gender focuses on the power, bravery and fearlessness of men is emphasized.
In the present study, there was a signi cant relationship between age and stress. It seems that as people get older, their level of energy reduces, they have more responsibilities and other social communications.
In addition, physical problems occur much more as people get older, which correlated with mental issues which justi es the relationship between age and stress.
This study showed that individuals infected by COVID-19, or those with a family member who was infected, experience a higher level of stress. In this pandemic, many people lost their loved ones which increases the mental pressures and threats they face. Individuals who have gone through the infection might feel ashamed and guilty. This only makes the condition of those suffering from special mental disorders worse. These people might face many psychological problems such as depression, anxiety, intense panic attacks, physical symptoms, nervous shocks and post-traumatic stress, delusions, psychosis and even suicide attempts. At younger ages, this makes people blame themselves more.
Mertens et al. (27) showed that the stress caused by losing one's family member or friends is more intense than the stress associated with one's life. In the study of Mertens et al., (27) worrying about the health of family members is reported to be the most signi cant concern of people and the best predictor of the coronavirus. These ndings are compatible with the ndings about the swine u in 2009-2010. The ndings of the study conducted by Mertens et al. (27) that another factor that has drawn lots of attention to itself, along with worrying about one's safety and behaviors associated with safety is the effect of the coronavirus on the health care system, economy and society. The participants of this study were worried about losing their job and/or changes that are made in their daily routines. These ndings are compatible with the results of the present study.
By reviewing the results of various studies focused on COVID patients in China at the time of spread of the coronavirus, it was reported that psychological disorders, such as depression, fear, anxiety, emotional transformations, insomnia, post-traumatic stress, were highly prevalent among these patients. The unbridled spread of COVID-19, the poor conditions of patients with respiratory problems isolated in the intensive care unit of the hospital, lack of an effective medicine and nally, the deaths caused by this disease, there are most important factors that can affect the patients' mental health (28,29).
According to the examinations, COVID-19 patients have a lower psychological tolerance. Given the current condition of this virus all around the world, these people are highly exposed to psychological disorders such as anxiety, stress, fear, depression as well as negative thoughts (29).
The results of a research on the quality of sleep of people in quarantine for 14 days at the time of spread of COVID-19 in China showed that sleep disorders are related to the anxiety and stress of these individuals and with the help of proper social support, the quality of sleep could be improved.
It also seems that there are some factors could affect the occurrence of such psychological symptoms in most people. Some of these factors are concerns with the risk of being infected, status of future career, source of income of individuals and families, as well as a long period of home quarantine (30).
University students are considered as other people who are likely to show such psychological symptoms at the time of the spread of the coronavirus. In such a way that at the beginning of the spread of this disease in Iran, like other countries in the world, the universities were among the rst organizations to be shut down as an effort to prevent the spread of COVID-19 at a larger scale. Based on the results of a research conducted in China throughout the H1N1 u pandemic in 2011, about two percent of university students showed symptoms such as post-traumatic stress (31).
According to the results of a study conducted in China on more than 1172 students at the time of spread of COVID-19, it was concluded that about 24.9% of the students experienced anxiety. Out of all students, about 9% of students reported symptoms of severe anxiety and mild anxiety (32).
One of the most important causes of anxiety among students is the concern with the effect of the coronavirus on the academic future, professional future and reduction of social communications. In addition, the anxiety factor among students might be the problem they face in paying the fees of their universities due to the loss of their source of income which might be caused by unemployment and loss of job.
Finally, based on the ndings of a research, one's family member's COVID-19 infection is another one of the factors that causes anxiety among students.
Various attempts have been made to support one's self and to reduce stress such as avoiding watching, listening to or reading about the same repeated news about the coronavirus which are shared by social media. Listening to the news over and over again in Iran and around the world is quite stressful and increases fear and concern (4).
At the time of quarantine, taking care of one's body by controlling stress becomes more and more important. Relaxation techniques, deep mindful breathing techniques, stretching and sports such as yoga are highly recommended. In addition, having a healthy and balanced diet, regularly working out, enough sleep and rest and nally, not smoking or consuming alcohol are some ways to take care of our body (5).

Conclusion
It seems that the psychological role of this disease on the people involved and on the public is completely known to everyone. In fact, it must be mentioned that focusing on the physical health structures and preventing the prevalence and treating this disease, special attention must be paid to the mental health of the society as well. For this purpose, basic psychological interventions and psychiatric disorders, including anxiety and depression, among members of a society seems necessary.