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 findings accompanied by quotes from the participants’ responses translated from Persian have been presented.
Stressful Conditions
The retrieved statements revealed stressful conditions filled 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 significant 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 predefined 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 identified 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 findings, 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 traffic 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 inflation rate. Now that this situation has arisen, the economic situation will definitely get worse. We may lose our jobs”[0429]
Most of the participants believed that the adopted policies in Iran such as social distancing had significant financial 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 findings from the content analysis indicated an increase in the prices of basic goods across Iran. Many people additionally cited higher inflation 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 difficult”[0884]
“Many patients have to pay a large part of the costs themselves. Heavy financial 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 difficult. The price of masks has increased by tenfold”[0052]
Decreased economic power of the public was another big concern identified 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:
“I work in the market. Now that the market is closed, I have no income. I have also lost my financial capital.”[0949]
“I really do not know what happens to my job and income. I am married and I have one child and I have to make the ends meet!”[1007]