The age of the participants ranged from 28 to 53 years. Ten of the participants were female and 5 was male. Twelve of the participants were married. Five of the participants were of health care provider and 10 were patient (Table 1,2). An example of a qualitative content analysis process is shown in Table 3. The theme was referred to as ‘Benefit and Barrier’. The meanings of the aforementioned categories and direct quotes of the participants are thus explained. After analyzing data, we extracted a total of 228 codes, 17 Sub-categories, 4 category and 1 Theme (Table 4).
Table 1 Characteristics of the patients with corona participating in the study
Duration of hospitalization(day)
|
Occupation
|
Marital status
|
Education
|
Age
|
Gender
|
Participants
|
2
|
Housewife
|
Single
|
Illiterate
|
33
|
Female
|
P1
|
7
|
unemployed
|
Married
|
Bachelor
|
36
|
Female
|
P2
|
10
|
Farmer
|
Married
|
Diploma
|
38
|
Male
|
P3
|
25
|
Housewife
|
Married
|
Primary
|
45
|
Female
|
P4
|
4
|
Retired
|
Married
|
Associate
|
53
|
Male
|
P5
|
6
|
Employee
|
Single
|
Bachelor
|
30
|
Female
|
P6
|
5
|
Employee
|
Married
|
Diploma
|
34
|
Female
|
P7
|
9
|
Self-employed
|
Married
|
Primary
|
44
|
Male
|
P8
|
5
|
Employee
|
Single
|
Bachelor
|
28
|
Female
|
P9
|
Table 2 Characteristics of the healthcare providers and managers participating in the study
Work experience (years)
|
Marital status
|
Occupation
|
Education
|
Age
|
Gender
|
Participants
|
24
|
Married
|
Head of the Health Center
|
Physician
|
51
|
Female
|
P1
|
10
|
Married
|
Head of the department of food and drugs
|
pharmacist
|
33
|
Male
|
P2
|
10
|
Married
|
Head of hospital
|
Master of science
|
38
|
Male
|
P3
|
20
|
Married
|
Head of the Health Center
|
Master of science
|
46
|
Female
|
P4
|
29
|
Married
|
Director of Infectious
|
Bachelor
|
51
|
Female
|
P5
|
18
|
Married
|
Nurse
|
Bachelor
|
41
|
Female
|
P6
|
Table 3 Sample of qualitative content analysis process
Meaning units
|
Code
|
Subcategories
|
Category
|
If the polymerase chain reaction
(PCR) diagnostic kit was available and enough, it could be performed for outpatients from the initial stages of diagnosis. Consequently, diagnosis was more accurate and definite. (p.3)
|
Poor diagnosis
|
Sanctions
|
Threats
|
A very crowded wedding was held in our village. The cook who made the food had corona and about 300 people were infected. Rural people do not take this disease seriously. (p. 7)
|
Ignorance of warnings
|
Wandering in the abyss of ignorance
|
We tried to keep in touch with the patients and suspicious cases. Due to the various false messages and videos, people were skeptical about whether we were really the medical staff and whether we were telling the truth or not. So, they did not answer their phones. (p.10)
|
Positive and negative impacts of the cyberspace and distrust of the media
|
Conflict between doubt and certainty
|
Due to the unknown and ambiguous nature of the disease, we thought that the virus would die as the weather gets warm. However, we were surprised when the number of patients went very high in the warm areas. (p.4)
|
Different symptoms with varying severity in patients
|
Hidden layers of the disease
|
Although 50 days had passed since I got the disease, my friends were still afraid of me. My co-worker did not come to the room where I worked and this made me upset. (p. 12)
|
Being afraid of patients, social stigma
|
Stigma
|
Table 4 Categories and sub-categories related to the patients, staff, and managers dealing with COVID-19
Sub-categories
|
Category
|
Theme
|
1.1 Each Home as a Health Post
1.2 Various media
|
- Strengths
|
Benefits and Barriers
|
1.3 Spirituality and Supporting ideals
1.4 Adaptive mechanisms
|
2.1 Low understanding of risk of disease
|
- Weaknesses
|
2.2 Lack of manpower and relief resources
|
2.3 Weakness in knowledge and Skill
|
2.4 Lack of appropriate tele-education and tele- medicine programs
|
2.5 Infrastructural constraints
|
3.1 Empathy and social participation
|
- Opportunities
|
3.2 Promote of skills
|
3.3 Obey the rules
|
4.1 Sanctions
|
- Threats
|
4.2 Wandering in the abyss of ignorance
|
4.3 Conflict between doubt and certainty
|
4.4 Hidden layers of the disease
|
4.5 Stigma
|
Strengths
This Category was about the Strengths in health system that which helped to better prevent and control COVID-19. The Sub-categories were Each Home as a Health Post, Various media, Spirituality and Supporting ideals, Adaptive mechanisms.
Each Home as a Health Post
“In the design of each home as a health post, each house had a health ambassador and was able to prevent the spread of the corona virus by caring for and educating its family members.” (Head of the Health Center, 46 years old).
Various media
The health message is effective when conveyed through a variety of educational media.
“In terms of information, they warned us several times through loudspeakers in the city and village. Operators of the 4030 system, which is an evaluation system for screening and preventing corona virus, also called us and followed our health status from moment to moment.” (patient 1, 33 years old).
A head health center stated: “We had a good status in terms of facilities, banners, posters, billboards, televisions of offices, and loudspeakers of mosques. All individuals were informed and warned about the corona virus. Despite the very severe sanctions, I think efforts of the healthcare staff were satisfying.”(Head of the Health Center, 46 years old).
Spirituality and Supporting ideals
The healthcare staff reported working more than normal work hours. Based on the reports, they were not tired of heavy and long shifts. They were striving for their ideals of gaining God's satisfaction.
"During this time my faith in God reached its peak because I heard that some people who were physically healthier than me died, but my wife prayed at my bedside and comforted me. God gave me energy, this was mere grace of God.” (patient 3, 38 years old).
“I saw a midwife changed diaper of a baby with corona and did not wait for the service personnel. I also witnessed that a nurse gave mask to a poor man”. (patient 7, 34 years old).
Adaptive mechanisms
All caregivers and patients used some mechanisms to reduce carerelated stress. They used a combination of problem-oriented and emotion-oriented strategies to reduce their stress.
I resisted the negative energy. I told my friends to be positive and think about health”. (patient 9, 28 years old).
Weaknesses
This Category was about the Weaknesses that were not seen and made the care experience challenging and difcult for caregivers, managers and patients. The Sub-categories were Low understanding of risk of disease, Lack of manpower and relief resources, Weakness in knowledge, Lack of appropriate tele-education and tele-medicine programs, Infrastructural constraints, Lack of readiness to make a vaccine.
Low understanding of risk of disease
Experts thought that the virus is weak. This low understanding showed that the necessary precautions were not taken against the disease.
“Many people were unprepared when the disease started. Our crisis headquarters thought that this was a small problem and our stockpile of personal protective equipment was running dangerously low. They did not expect such a crisis.”( Head of the department of food and drugs, 33 years old).
Lack of manpower and relief resources
“We experienced a lot of stress, we did not have a psychologist or a social worker in the hospital. A number of nurses, midwives, and doctors were scared and could not give proper psychological counseling to patients, but there was no one to comfort them. The presence of a psychiatrist and psychologist should be mandatory in the hospital. Now, We dont have psychiatrist and psychologist.”( Director of Infectious, 51 years old).
Weakness in knowledge and Skill
Many participants did not have enough knowledge about the type of virus and its mutations. In addition, knowledge of the use of contraceptives such as disinfectants was poor. they applied all of their previous care knowledge and experience, but the patient’s symptoms did not improve signifcantly or recur.
A Head of hospital said: “I do not know the exact details of the virus, it is not clear to us. This has made it difficult for us to fight the virus. We need to talk more about disinfection and the percentage of alcohol required, many of our computers burned down. We have to consider the details. I have this knowledge, but in practice I doubt it.”( Head of hospital, 38 years old).
Lack of appropriate tele-education and tele-medicine programs
Tele-education and tele-medicine are the two main arms of preventing and controlling COVID-19.
“At the moment, our biggest problem and weakness is lack of the tele-education and tele-medicine programs. By implementing the tele-education program, we can provide health and medical services to people without asking them to leave their homes and refer to the health centers. It is not possible to force people to stay home without providing them with the required health service.”( Nurse, 41 years old).
Infrastructural constraints
This sub-category included the experts’ viewpoints about the inadequacy of infrastructures in terms of physical space, quality deficiencies, and availability of the materials needed to prevent and control disease.
“We do not have an isolated room with negative pressure ventilation in our hospital. According to the standard, our isolators should have negative pressure ventilation, but because we do not have such a room, we isolate patients with coronal in a separate room with a separate bathroom, so that they do not have any contact with others.” (Head of the Health Center, 51 years old).
Furthermore, a head of hospital cited: “It takes about 48 hours to prepare the tests’ results after sampling in our university. During this period (when the patient is waiting for the test results), a large cost is imposed on the hospital and many human resources are involved. In addition to costs, the patient is exposed to high levels of stress due to distance from family.” (Head of hospital, 38 years old).
Opportunities
This Category was about the Opportunities that Outside the health system which helped to better prevent and control COVID-19. The Sub-categories were Empathy and social participation, Promote of skills, Obey the rules.
Empathy and social participation
A large number of people and departments volunteered to cooperate, which reduced the workload on healthcare staff. Furthermore, the family members support patients and instill hope in them to survive the disease.
“The police, revolutionary guard corps, Red Crescent, benefactors, and people disinfected streets and passages every night. People also sewed masks benevolently.” (Head of the Health Center, 51 years old).
Family support of patient, especially emotional support, was recognized as the most important factor in preventing and controlling the disease.
“My wife was pregnant when I was admitted in the hospital; she took after me with great effort and patience. Her sacrifice motivated me to try to get better. It was not the medicine that helped me get better, but my wife's love.” (Patient 3, 38 years old).
“Now, I realized how important we are to each other,I feel we got closer.” (Nurse, 41 years old).
Promote of skills
Some caregivers, especially younger individuals, stated that the experience of caring for a critically ill patient made them stronger and more responsible and provided them with a sense of growth.
“I became much stronger, as I gained experience and skill how to protect myself from fear and stress.” (Nurse, 41 years old).
Obey the rules
When regulations are enforced more strictly, people obey.
“Noruz holidays and traffic restrictions in our country were a great opportunity that enabled us to prevent the virus transmission to people. If the traffic restrictions continued for several months after the holidays, maybe we could control the disease.”( Head of the department of food and drugs, 33 years old).
Threats
This Category was about the Threats that were outside the health system Which made it difficult to prevent and control the disease. The Sub-categories were Sanction, Wandering in the abyss of ignorance, Conflict between doubt and certainty, Hidden layers of the disease, stigma.
Sanction
Severe sanctions against Iran slowed the prevention and control of the disease
“If the PCR diagnostic kit was available and enough, it could be performed for outpatients from the initial stages of diagnosis. Consequently, diagnosis was more accurate and definite. Also the people ask about error rate of the tests; the fact that these tests had an error rate of about 40% made the system very uncertain.” (Director of Infectious, 51 years old).
Wandering in the abyss of ignorance
Considering prolongation of the disease and closure of the wedding halls, people held weddings at home, which caused crowds and a lot of communication among people.
“A very crowded wedding was held in our village. The cook who made the food had corona and about 300 people were infected. Rural people do not take this disease seriously.” (Patient 5, 53 years old).
Regarding disposal of the personal protective equipment, a large number of people and personnel were unaware of the instructions on separation and disposal of the wastes.
“Patients and suspects who use masks and personal protective equipment are told to throw the generated waste in special bins, but there are a lot of used masks and gloves outside the hospital and on the side of the streets.” (Head of hospital, 38 years old).
Conflict between doubt and certainty
The participants' internal struggle about what is right or wrong was one of their major concerns.
“Virtual networks have both positive and negative effects. After some businesses were disrupted, some groups in the virtual networks started destroying and blaming the health care system. Now, people do not accept the health care system recommendations”. (A head health center, 46 years old).
The patient said: “Since there are so many fake messages, videos and channels, people were skeptical about whether the healthcare staff were telling the truth, Therefore, people did not answer their phones.” (Patient 8, 44 years old).
Hidden layers of the disease
Corona virus is an emerging disease; in other words, a new discovery is made about it with each passing day.
“Given the unknown and ambiguous nature of the disease, we thought that the Corona virus would die as the weather gets warm. However, we saw that the number of patients increased in the warm season.” (Head of the department of food and drugs, 38 years old).
stigma
Some factors, such as the community attitude, can explain the vulnerability caused by social support. If social relationships are not maintained at a proper level, it can have the opposite effect.
“I want to be treated like a normal person when I go out, but people bother me and I feel depressed” (patient 3, 38 years old).