Volume 5, Issue 3 (Spring-Special Issue on COVID-19 2020)                   Health in Emergencies and Disasters Quarterly 2020, 5(3): 127-138 | Back to browse issues page

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Javadi M H, Sayar S, Sabzi Khoshnami M, Noruzi S, Memaryan M, Azari Arghun T, et al . Investigating People’s Anxieties and Concerns About COVID-19. Health in Emergencies and Disasters Quarterly. 2020; 5 (3) :127-138
URL: http://hdq.uswr.ac.ir/article-1-289-en.html
1- Department of Social Work, School of Behavioral Science, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2- Department of Sociology, Faculty of Management & Social Science, North Tehran Branch, Islamic Azad University, Tehran, Iran.
3- Department of Social Work, Faculty of Social Sciences, Allameh Tabatabai University, Tehran, Iran.
4- Department of Educational Psychology, Faculty of Educational Sciences and Psychology, Alzahra University, Tehran, Iran.
5- Department of Sociology, Faculty of Social Science, Central Tehran Branch, Islamic Azad University, Tehran, Iran.
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1. Introduction
Coronaviruses comprise a family of viruses. The disease is typically characterized by fever, fatigue, and dry cough. Some patients have symptoms such as mild to severe muscle pain, headache, sore throat, nausea, and diarrhea. These symptoms initiate gradually and mildly. Respiratory problems occur with increasing the severity of illness [1]. Various health organizations around the world have reported various incubation periods for the COVID-19. The World Health Organization (WHO) has reported 2-10 days, the China National Health Commission 10-14 days, and the US Centers for Disease Control and Prevention 2-14 days for this incubation period [2]. Subsequent investigations have demonstrated that the disease originated in the seafood, poultry, and live animals market located in Wuhan City, Hubei Province, Central China [3]. Afterward, an unprecedented prevalence of pneumonia was reported to the World Health Organization on December 31. On January 1, 2020, the market was closed and decontaminated. After widespread speculation about the cause of the disease, the Chinese section of the Centers for Disease Control and Prevention (CDC) eventually confirmed the report published by the Wall Street Journal and announced on January 9, 2020, that the cause of the disease was a new Coronavirus called COVID-19 [4].
Following the increasing number of patients and spread of the virus worldwide, the World Health Organization (WHO) stated on January 30, 2020, that the new Coronavirus has become the sixth leading cause of public health emergency worldwide, threatening not only China but all countries in the world [5]. The spread of the disease was so severe that on April 24, 2020, it affected almost all countries in the world. The number of infected individuals on this date was 2700000 people, of whom about 190000 died.
In Iran, following the death of two patients in Kamkar Hospital in Qom City, on February 20, the virus spread, and until August 8, according to the Ministry of Health report, 322567 people got infected by the virus throughout the whole country. Since the onset of the disease outbreak, medical centers as the pioneers in fighting against this virus took actions and medical and health staffs provided valuable services and support in this respect. But the complexity, novelty, and high infection rates of the disease have led most people to spend their lives under the fear of exposure and getting the diseases. The feelings of anxiety and stress that in many circumstances induce psychosocial disorders among individuals and have a detrimental impact on human wellbeing and immune function. Thus, given the spread of the disease throughout the country and its consequences on different aspects of human lives, it is essential to carry out this investigation to recognize people’s fears and concerns regarding this disease. Then the research findings are presented to the responsible authorities to take appropriate measures and plannings to respond to these fears and preserving the health dimensions (physical, mental, social, and spiritual) of community members and minimize the fears and anxieties due to this disease. Also, this research could be used as a research document in possible future crises.
2. Materials and Methods
The present study was performed by qualitative content analysis. The methodology of data processing is the conventional content analysis method. The qualitative content analysis method can be considered as a research approach for subjective interpretation of textual data content through systematic classification, coding, and theme building processes with the design of known patterns [6]. The qualitative content analysis goes beyond the words or objective content of texts and tests themes or patterns that are explicit or implicit as explicit content. The analysis process can be influenced by the type of categorization and analytical inductive approach or deductive analytical study as well as a selective technique for analyzing summary, descriptive, and structured data. But obviously, the qualitative content analysis will strongly be affected by its quantitative counterpart and also the research questions that the investigator is supposed to answer. Nevertheless, whichever categorization or methodology that is being used, the selection and implementation of text and data management, categorization and coding, analysis, and interpretation are very important in this analysis [7]. This study seeks to answer the general question of “What are the common concerns and questions of the general public about COVID-19 disease?”
In this study, the purposive sampling technique was used. Data on fears and concerns of the overall population were collected through social workers serving at the university/ medical school throughout the country, affiliated healthcare centers, hotline 190, and social media. The data collection process was saturated with 2920 theoretical data from February 27, 2020, to April 3, 2020.
The inclusion criteria for social workers were as follows: social workers serving at referral health centers; and declaration of their willingness to cooperate in research.

The inclusion criteria for social networks were as follows: using reputable and reliable Persian news sites and sources related to people’s concerns about COVID-19;  and documents and content of virtual social networks related to concerns and worries about COVID-19.
After initial coding and ensuring the validity of the findings, we used the immersion method and continuous struggles of researchers with the data. Also, to assure the accuracy of the data, people with experience in peer debriefing were requested to review the interviews and the initial coding and concept classes, and repeated reviews were performed. To maintain consistency, the content was reviewed in two stages, one when 10% t0 15% of the categorizations were completed and the other at the end of the process.

3. Results
According to the results of the study, fears and concerns of community members were categorized into 8 areas: 1. Confusion in communication with the surrounding environment; 2. Concerns about vulnerable groups being affected; 3. The necessity of informational support; 4. Economic turmoil; 5. Shortage of preventive and treatment facilities; 6. The weakness of social capital; 7. Stressful and destructive atmosphere; and 8. Approaches for crisis management situation (Table 1).
4. Discussion
In this study, we investigated the important aspects of current people’s fears and concerns about special conditions because of COVID-19. These anxieties and concerns are as follows: 
1. Confusion in communication with the surrounding environment is seen in two areas: A) Feeling of threatening from public gatherings. In this context, people are concerned about attending places such as shrines, offices, passenger terminals, etc. Therefore, in this regard, it is essential to provide guidelines for preventive tips. B) Forced distancing from the family: Many people, especially medical staff, have concerns about contacting their families (children and parents) and in this situation, they have adopted forced distancing to protect the family from getting infected. Therefore, in this area, supportive services such as providing psychological and social assistance through social workers can be effective [8].
Regarding the structure of the society, one of the people’s concerns is attending religious places and shrines. Research shows that the presence of people in religious places and participation in religious ceremonies such as pilgrimage and worship has consequences such as reducing mental disorders, anxiety, and anger [9], but with the outbreak of the disease and the closing down of shrines and also the abolition of all religious ceremonies, prevented the people from the comfort of these holy places to alleviate their fears and anxieties. 
Also, due to the fear of being infected with the Coronavirus, families avoid attending ceremonies such as funerals and mourning of loved ones, which leads to disorders such as mental health conditions and delayed grief [10, 11].
With regard to the fast spread of the virus, worries about social relationships have intensified and social communication is not possible like before, while experts like Turner believe that one of the factors that influence depression and stress in critical situations is social relationships. Social relationships help people deal with crises when unfavorable situations occur and reduce their psychological tensions caused by stressful conditions [12]. Because of similar experience in China, serious issues, such as fear of death among patients and frustration and anxiety of isolation, appear in quarantined individuals. People in quarantine lose the opportunity to have personal and social connections and also miss the chance of holding traditional ceremonies, which is itself a stressful phenomenon [13]. Besides, people who become quarantined lose face-to-face communication and traditional social interventions, and this is a stressful phenomenon [14].
2. Research results in the context of concern about the getting infected of vulnerable groups were discussed in three parts:
A. Awareness of vulnerable age groups; B. Detection of at-risk groups; C. Concern for the socially-disadvantaged groups. Because the elderly and people with specific and underlying diseases are among the high-risk groups in terms of being affected and treatment, the families of these people are more under stress and feel anxiety [15]. Also, the rumors that this is a man-made virus to remove unproductive and worn-out forces in the general public have sparked fears within family members [16]. Meanwhile, socially-disadvantaged groups such as addicts, working and street children, homeless people that are underprivileged in terms of accessibility to healthcare services and preventative measures, and do not have enough knowledge and understanding about the disease can exacerbate the progression of the virus throughout the general public. This is another concern raised by the people. In these two areas, some interventions are suggested to reduce people’s worries and concerns. Firstly, guidelines should be given regarding prevention in at-risk and high-risk age groups, then some measures should be taken regarding education and awareness, as well as providing preventive equipment and facilities for the socially-disadvantaged groups in cooperation between the Ministry of Health and the Welfare Organization.
3. The necessity of informational support in multiple areas was raised by the people. Since this virus is novel and some of its characteristics are unclear, the absence of adequate understanding regarding the infection promotes ambiguity, distress, and tension among people in the general population. Therefore, education in the proposed areas to individuals in the community with the increasing focus towards expressed requirements is essential, A. The need for climate knowledge; B. Nutritional concerns; C. The clarification of the cleanliness ambiguities; D. Guidelines for prevention and treatment; E. Mechanism of the burial of the deceased; G. Seeking for signs and symptoms of Coronavirus; and H. The possibility of transmission from animals.
4. Economic turmoil, which is one of the major consequences of this disease throughout the country and around the world, was discussed in two domains: A. The financial burden of the disease; one of the people’s concerns is how to provide the cost of the disease and its treatment. This requires the government’s support and transparent information about how the disease costs for all community members; B. Helplessness of living expenses: Many people in the community, particularly those who have services-related and low-wage jobs (taxi drivers, peddlers, etc.) have lost their income due to these conditions, and their main concern is earning a living. Therefore, the anticipation of subsistence packages and financial assistance is vital to compensate for low-income workers and disadvantaged people of the society.
5. Concerns about the shortages of preventive and treatment facilities were presented in two aspects: A. Challenging access to safety equipment; B. Inappropriateness of medical facilities with the spread of the disease. As the shortage of preventive services in the society and lack of access to them made people worry and terrified resulted in emotional responses (such as hoarding, etc.), it is recommended that these facilities be made available throughout the society with equal access to comfort the people.
6. Weakness of social capital was mentioned in two areas: A. Distrust in reported statistical data: As contradictory information has been provided to the public through virtual networks and Western media, people have lost trust in the government and have a lower sense of solidarity with the government; B. Criticism of the authorities’ performance has been raised with issues such as non-cancellation of Mahan flights from China, lack of monitoring of hoarding and an increase in the price of masks and gloves, etc.
7. There are two concepts in the issue of stressful and hazardous environments. A. Widespread fear of disease; B. Insufficient responsibility of people in fighting the disease. At the moment, one of the most common problems is the fear and anxiety of people about getting the disease. With increasing the mortality rate, many patients experience mental problems and stress [17]. Crisis intervention, online consultation, and self-care training are effective for individuals who experience anxiety, stress, loneliness, and trauma [18]. Another cause of people’s tension is the weak responsibility-taking of some people to follow health care protocols and their high-risk behaviors such as holding funerals and weddings, etc., which provoke the spread of the disease throughout multiple geographical regions. Since there is no proven therapy for the Coronavirus, prevention is the most valuable manner to control the virus, so to contain disease outbreaks, we require participation, social responsibility, and solidarity.
According to sociologists such as Kent, the consensus is the foundation for the formation of social solidarity, and the national consensus is based on values ​​and moral rules, and the acceptance of these values ​​by the majority of society. In Iranian society, with regard to the collectivist culture and national and religious values ​​based on unity and solidarity, we have always seen that in critical conditions and natural disasters such as earthquakes and floods, new structures are formed based on these values ​​and has created social solidarity and collective participation [19]. Therefore, in the current situation and the spread of Coronavirus disease, this cultural capability can be used to promote social solidarity.
8. Approaches for crisis management situation: In this regard, recommendations have been made by the people to control and reduce the consequences.
Findings and research observations can be classified into two sections. In the first section, with regard to the concerns due to the confusion in the communication with the surrounding world, the concern of infection of vulnerable groups, the necessity for informational support, economic turmoil, and shortages of prevention and treatment equipment, providing social support is important. Social support encompasses several dimensions of accessibility to instrumental, emotional, and informational support. Instrumental support refers to the material, objective, and real assistance received from others. This type of support helps people to meet their daily needs and includes such material and objective assistance such as granting loans, livelihood packages and providing preventive equipment such as masks, gloves, etc. Emotional support includes empathy, care, and attention to people. This type of support can help a person feel comfortable, confident, belonged, and loved in periods of stress and critical situations [20]. Informational support helps to understand an issue and problem. This type of support refers to information that a person can use against problems and includes advice and suggestions to people to deal with the crisis [21].
The second dimension of the findings, i.e., distrust in published statistics, criticism of managerial performance, poor responsibility of people in observing preventive steps, demonstrate a reduction in social capital within society. Social capital refers to various aspects of social organization such as trust, norms, and networks that can improve the efficiency of society by facilitating coordinated actions. In a society where social capital is declining, social solidarity decreases, and individuals become socially isolated. Social capital creates social cohesion, trust, and a desire to engage in social action. It can reduce stressors related to health [22]. Therefore, increasing social capital to control and resolve crises in societies is one of the main measures of governments.
5. Conclusions
Based on research results, concentrating and attention on people’s concerns transparently and designing novel psychosocial supportive systems based on people’s specific requirements to handle the spread of the disease results in an improvement in social capital between community members and consequently solving the crisis rapidly. Overall, the outbreak of COVID-19 has a significant effect on the physical, mental, social, and spiritual health of society members, affecting the normal events and activities of daily routine, has changing current service delivery systems, and disrupting community connections. While all of these changes and developments have occurred rapidly and on a large global scale. All of these incidents have caused shock and bewilderment in societies and have increased people’s mental focus on the topic of COVID-19 and its consequences. At the same time, it must be accepted that government authorities and social programmers have been similarly influenced by the crisis and had to rearrange the structures and methods of service delivery in a brief period. Meanwhile, the worries and concerns of the people are considered an extra psychological burden on the service providers in this period.
However, with the approach of turning threats into opportunities, we could use the mental focus of society on this topic and their concerns over social participation to eliminate their social concerns and desirably creating responsibilities. Participation refers to the process of using the individual/group capabilities of beneficiaries to accomplish a collective objective. In this process, conscious behavior, collective desire, collective acceptance, choice, and the existence of common needs are important. What is important in a successful participation process is the feeling of the necessity to solve a problem, recognizing that problem, and feeling the necessity for community collaboration according to their level of understandings, capabilities, awareness of available capacities and facilities, and their optimum utilization [23].
In this regard, social participation is based on three models: working for the people, working with the people, and working through the people. The best model that creates the highest level of participation and leaves the highest level of effectiveness and sustainability of services is the work with the people model. In this community-based model, the main activities are the responsibility of the people and governmental or non-governmental institutions have the role of coordinator and facilitator.
In the current environment, due to the use of cyberspace by individuals in society and the need to reduce face-to-face communication, we can use the community-based approach and social participation of people in these spaces to reduce their worries and concerns. Some of the proposed methods are to create campaigns focusing on providing reliable information, identifying and supporting at-risk groups, forming self-help groups, sharing resources and capacities, and other issues of public concern. Government institutions, in addition to developing social participation, should revise their defined roles according to the existing conditions and seek to create new, creative methods that can cover all areas. Government institutions can help strengthen NGOs, mobilizing resources, and effectively strengthening efficient projects while fulfilling their roles at the levels of planning, policy, and service delivery, which could enhance social capital and directing society goals for overcoming this crisis. 
With regard to the comprehensive collection of people’s concerns and worries about COVID-19 based on the progression of the disease and its consequences over time, the policymakers and planners in the health sector are suggested to present the results in the think tank and to address the concerns of the people, with the presence of experts, people’s representatives, etc., and then local interventions should be designed based on the needs of the people and provided to the people through a specific procedure.
Ethical Considerations
Compliance with ethical guidelines
The subject of the research was approved by the Scientific Committee of the Hospital Management Center and the Clinical Services Excellence of the Deputy Minister of Health and was sent to the country’s universities by letter No. 255/400. In all stages of the research, the principle of confidentiality was observed and the necessary measures were taken to prevent the publication of information and details of the participants. 
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Authors' contributions
All authors contributed in preparing this article.
Conflict of interest
The authors declared no conflict of interest.
We appreciate the authorities of social services of medical universities in the country and university social service students of the University of Social Welfare and Rehabilitation Sciences, including ladies Arezoo Rashedi, Fatemeh Pakdaman, Fatemeh Mostafaei, Mahsa Rased, Fatemeh Gholami, Zeinab Morsali, Zahra Jalalian-Gloo, Fatemeh Sheikh Taheri, Fatemeh Jafari, Atefeh Abdullah Nejad and Fatemeh Haqqani who helped us in this research.

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Type of Study: Research | Subject: Special
Received: 2020/03/13 | Accepted: 2020/03/18 | Published: 2020/04/1

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