Original Article

A Survey of Awareness and Stress of Coronavirus Disease 2019 in a Part of the Iranian Population

Background

Coronaviruses are a large family of viruses that cause a wide range of diseases in mammals and birds. The infection of the members of this viral family leads to a broad set of clinical symptoms ranging from the common cold to chronic respiratory illness (1). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a new virus was spread from this family in 2019, and the World Health Organization called the causative agent of the novel coronavirus disease as 2019-nCoV (2). Six species of coronaviruses capable of causing infection in humans were identified until December 2019. Among these species, SARS and the Middle East respiratory syndrome (MERS) coronavirus caused a worldwide pandemic and were associated with high mortality in 2002 and 2012, respectively (3).

The sequence of genomic nucleotides in bats (Rhinolophus affinis) was first discovered in Wuhan, China and was 96.2% similar to the virus, suggesting that the bat is probably the natural host of the virus. Due to genetic differences, the existence of an intermediate host other than pangolin, a small mammal whose genome shows about 99% similarity to the virus, is possible (4). The incubation period of the disease in infected people usually lasts between 14 and 20 days although symptoms develop after 24 days in some people (5).

The prevalence of this virus is higher in men compared to women. After the incubation period, most infected people have clinical manifestations of a mild to moderate respiratory illness, including fever, dry cough, a feeling of tiredness, and muscle aches, as well as shortness of breath which can be treated with adjuvant therapy. The occurrence of this disease is more severe in the elderly who have underlying diseases such as diabetes, cardiovascular disease, cancer, hypertension, and obesity (6). With the rapid spread of coronavirus disease 2019 (COVID-19), it is now becoming physically and mentally urgent in just a few months. The prevalence of this disease is constantly increasing and thus causes concerns related to community health and may lead to serious psychological problems such as anxiety and uncertainty. Nonetheless, it can be prevented with medical and psychiatric treatment (7-9).

Anxiety is a common symptom in patients with chronic respiratory disorders and can significantly reduce the quality of a patient’s life. In almost all cases of anxiety, it also includes physical cases which can be accompanied and overlapped by the symptoms of the chronic respiratory disease and drug side effects (10). Anxiety about COVID-19 is common mostly due to ignorance and confusion among people about the virus. Fear of the unknown reduces the perception of immunity and has always been stressful for humans (11). Therefore, with the increasing expansion of COVID-19 in the world, this study was designed with the purpose to assess the level of awareness and stress of the COVID-19 in the population of Iran.

Materials and Methods

This study utilized a cross-sectional survey design. Due to the widespread outbreak of coronavirus and the lack of face-to-face access to individuals, the authors created a questionnaire in Google Docs and then sent it to people virtually via WhatsApp, Telegram, Instagram, and Email. Public participation in the present study lasted from May to the first week of July 2020. The total sample size was 201 people and the population size was 420 people according to the Morgan table. Electronic consent was obtained for participation in the survey front page of the survey that was completely voluntary and any person could cancel and withdraw by not sending a reply. This tailored-made questionnaire has been scheduled in the Persian language to have easy access to everyone.

The approximate time to complete the questionnaire for each person was about 15-25 minutes, which was set by the questioner in the web environment and its link was sent without any interference or capture. It should be noted that the objectives of the project were thoroughly described for each person at the beginning of the electronic questionnaire and before completing the questionnaire.

Data Collection

Data collection tools included a demographic information checklist consisting of data about age, level of education (high school, diploma, associate degree, bachelor, master, and doctorate), employment status (employee, student, self-employed, and unemployed), and location (all cities of Iran but mostly in the north portion and the centre of the country). The checklist also contained the source of information about coronavirus (national media, internet and article, social networks, and other sources). In addition, other applied instruments were two questionnaires that included questions related to measuring the level of awareness and stress about COVID-19. The statistical population of the participants in this study was in the age range of 13-85 years.

Data Analysis

The responses in the case of the questions related to measuring awareness and stress were recorded on a three-scale (yes = 2, No = 1, No answer = 0). The total score of the questionnaire for assessing people’s awareness was between 0 and 28. The criterion for measuring the level of awareness was the number of yes answers, and the total contractually obtained scores were classified into weak (0-14), medium (14-21), and favorable (21-28) groups. The total score of the questionnaire for assuming the level of stress was between 0 and 12, and the measure of stress was the number of yes answers and the total points obtained contractually were classified into weak (0-6), medium (6-9), and favorable (9-12) categories. The validity of each questionnaire was assessed by content validity through research professors in the field of viral diseases and psychology (3 psychologists and 2 microbiologists). The content validity of all items based on the content validity ratio and content validity indexes of the questionnaire was confirmed and considered as 0.99. Moreover, their reliability after statistical analysis by calculating Cronbach’s alpha was determined as α = 0.779 and α = 0.847 for awareness and stress questionnaires, respectively (Table 1).

Data analysis using IBM SPSS Statistics (version 24) was performed through descriptive statistical indicators (e.g., frequency percentage, mean, standard deviation, agreed tables, and chi-square test). The significance level in this study was considered 0.05.

Results

In general, 51.7% and 48.3% of participants were women and men, respectively. The mean (standard deviation) of age in the study population was 29.18 ± 9.95 with a maximum of 85 and a minimum of 13 years. The majority of the included people (n = 201) were from the north (69.7%) and center (16.42%) of Iran, respectively (Figure 1). In addition,46.3% (n = 93) and 38.8% (n = 78) of them had a bachelor’s degree and were students, and their source of information was national media 33.8% (n = 68, Table 2).

Close

Figure 1.

Distribution of Study Samples Across Various Cities of Iran.

Figure 1.

Distribution of Study Samples Across Various Cities of Iran.

Most participants (96.6%, n = 201) knew about COVID-19 (They were ranked in the middle and upper awareness score category) and 90% (n = 181) of them indicated that a virus was the cause of COVID-19. In this study, 97% (n = 195) of people had good information about the ways of spreading this disease and 47.3% (n = 95) of them considered this disease as a biological weapon (Table 3).

According to the global prevalence of COVID-19, 85.1% (n = 171) of participants were stressed and worried that they and their relatives would get infected and 76.1% (n = 153) of cases wanted to receive up-to-date information regarding disease control and care (Table 3).

The awareness of the majority of people was at a desirable level (71.6%, n = 144). Based on the results, the highest level of awareness (desirable class) about COVID-19 was related to the age range of 21-40 years (86.1%, n = 124) who had a bachelor’s degree (50.7%, n = 73) and were students (34.7%, n = 50). However, the lowest level of awareness (poor class) belonged to those who were within the age range of 21-40 years (71.4%, n = 5), had a bachelor’s degree (57.1%, n = 4), and were unemployed (42.9%, n = 3). The awareness score showed a statistically significant relationship between the education level (P = 0.031) and individuals’ age (P = 0.000) while there was no statistically significant relationship between the awareness score and job (P = 0.144, Table 4).

The findings revealed that the stress level of most participants with coronavirus was moderate and high (90.6%, n = 201), and the maximum percentage related to the highest level of stress (optimal class) due to coronavirus belonged to people aged 21-40 years (86.7%, n = 72) who had a bachelor’s degree (50.6%, n = 42) and were students (41%, (n = 34). Conversely, the lowest level of stress was observed in people aged 21-40 years (73.7%, n = 14) who had a bachelor’s degree (42.1%, n = 8) and were unemployed (42.4%, n = 8). Based on the findings, a statistically significant relationship was found between stress and job (P = 0.032) while no statistically significant relationship was observed between the education level (P = 0.657) and age (P = 0.053), the details of which are provided in Table 4. The demographic characteristics of the participants as well as the percentage of awareness and stress questions are shown in the Figure 2.

Close

Figure 2.

Percentage of Awareness and Stress Questions in a Part of Iranian’s Population.

Figure 2.

Percentage of Awareness and Stress Questions in a Part of Iranian’s Population.

Discussion and Conclusion

The results of the study showed that out of 201 people, 104 (51.7%) and 97 (48.3%) of the population responding to the questionnaire were women and men, respectively. The mean age of individuals was 29.18 ± 9.95. According to statistics, 46.3% of people with university education and 33.8% of the participants obtained the necessary information through the national media (radio and television) on average.

Additionally, various statistical studies have focused on COVID-19 in Iran and other countries. In a study conducted by Taghrir et al on 240 Iranian medical students including 98 (40.8%) males and 142 (59.2%) females, the average age of the subjects was calculated to be 23.67 years, which had a younger population (12) compared to the present study. Likewise, Alipour et al evaluated 378 people containing 229 (74%) men and 80 (26%) women of the Iranian population using a virtual questionnaire. Based on their findings, only 105 (34.1%) cases had a bachelor’s degree (13), showing a close relationship with the results of the present study. The most important data source in the coronavirus is media such as television, radio, social media (e.g., Telegram and Instagram), Satellite TV, websites, and corporate text messages, along with face-to-face conversations. In this crisis, providing valuable information to all people with different age groups, gender, education level, and living situation is a difficult and time-consuming task (14).

With regard to participants’ awareness, the upcoming study indicated that most of them (96.6%) were familiar with the COVID-19 and 90% of cases identified it as a virus through media reports. Based on the obtained data regarding measuring people’s level of awareness, no significant relationship was found between the education level and age while there was a relationship between ….. and people’s job. The results also showed the desired level of awareness with a frequency of 86.1%.

In their study, Fallahi et al reported that the level of awareness was desirable (above 50%). There was a significant relationship between COVID-19 awareness and gender (15), which is in line with the results of the present study. Similarly, Rahmanian et al survived medical students and concluded that 98.3% of them were familiar with the disease and 95% of cases identified the coronavirus as contagious (16), which is highly consistent with the findings of the current study. Similar to our study, the relationship of students’ awareness with the education level was significant in the above-mentioned study. On the other hand, the results of the study by Nasirzadeh et al on the citizens of Qom province represented no significant relationship between awareness and the education level (17), which is inconsistent with the findings of the present study.

Peng et al accomplished a study on 872 participants, comprising 534 (61.2%) females and 338 (38.8%) males. In this study, women’s awareness score (82.3%) was higher compared to men, and 73.81% of women had a positive attitude in this regard (18), which corroborates with the results of the current study.

Despite access to accurate information about COVID-19 by passing time and knowing more about the disease and ways to prevent and control it, there is still disagreement between different communities in most developing countries. It is important to propagate the right information about COVID-19 because up-to-date awareness and useful information in all aspects can reduce the spread of the disease and the mortality rate (19).

In this survey, 85.1% of participants were stressed and worried about themselves and their relatives regarding COVID-19 and 76.1% of them were willing to receive information on ways for caring and controlling this disease. Participants had moderate-to-high levels of stress and ages 21-40 were classified in the high level. There was a significant relationship between job and stress (P = 0.032).

In an investigation conducted on the staff of Masih Daneshvari hospital in Tehran, Esmaeili Dolabinejad et al reported that the levels of stress and anxiety due to COVID-19 had the highest rate of psychological damage in those who were in the age range of 20-30 years. In the present work, the stress was also at a moderate-to-high level and the injuries caused by this disease were observed in the age range of 40-21 years (20), which is in conformity with the result of this study.

The findings of the research by Fathi et al on 252 students of Tabriz Azad University containing 208 women and 44 men indicated that students’ anxiety was significant. They found that the stress caused by COVID-19 plays a remarkable role in their concentration and learning. However, no significant relationship was observed between education and anxiety in this study (21). A study by Qian et al in China revealed that the stress rate of COVID-19 in Wuhan residents was 32.7% and that of the Shanghainese people was 20.4% ranging from moderate to severe (22).

From the perspective of health psychology, the psychosocial effects of coronavirus can be traced on patients, medical personnel, patients’ families, community, children, the elderly, and the effects of mourning on the survivors. Although a slight level of anxiety is required for general sensitivity, previous experiences with a high prevalence of dangerous diseases indicate a high potential for general panic, which is often more dangerous than the disease itself (23). According to studies, patients with COVID-19 have a low psychological tolerance capacity and due to the current state of the disease in the world, these people are highly exposed to psychological disorders such as anxiety, fear, depression, and negative thoughts. If left untreated and uncontrolled, Psychological disorders may cause permanent injuries in patients such as the influx of disturbing memories, avoidance behaviors, and irritability (24).

Authors’ Contribution

All authors contributed to the collection, calculation, and writing.

Ethical Approval

All participants completed the questionnaires with informed consent.

Conflict of Interests

The authors declare that there is no conflict of interests associated with this publication.

Acknowledgments

We feel obligated to thank all those who truly dedicated their lives to fighting COVID-19, people and the media are trying to prevent this epidemic with scientific information.

References

1. Emadi M, Taghinejad J, Ghaffarzadeh A. A review of the SARS-Cov-2 immunological study. J Sabzevar Univ Med Sci 2020; 27(5):614-9. [ Google Scholar]
2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395(10223):507-13. doi: 10.1016/s0140-6736(20)30211-7 [Crossref] [ Google Scholar]
3. Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol 2019; 17(3):181-92. doi: 10.1038/s41579-018-0118-9 [Crossref] [ Google Scholar]
4. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020; 12(1):9. doi: 10.1038/s41368-020-0075-9 [Crossref] [ Google Scholar]
5. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Surveill 2020; 25(5). doi: 10.2807/1560-7917.es.2020.25.5.2000062 [Crossref]
6. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv. 2020. 10.1101/2020.02.06.20020974
7. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020; 395(10223):470-3. doi: 10.1016/s0140-6736(20)30185-9 [Crossref] [ Google Scholar]
8. Sun L, Sun Z, Wu L, Zhu Z, Zhang F, Shang Z, et al. Prevalence and risk factors of acute posttraumatic stress symptoms during the COVID-19 outbreak in Wuhan, China. medRxiv. 2020. 10.1101/2020.03.06.20032425
9. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020; 7(3):228-9. doi: 10.1016/s2215-0366(20)30046-8 [Crossref] [ Google Scholar]
10. Dong XY, Wang L, Tao YX, Suo XL, Li YC, Liu F. Psychometric properties of the Anxiety Inventory for Respiratory Disease in patients with COPD in China. Int J Chron Obstruct Pulmon Dis 2017; 12:49-58. doi: 10.2147/copd.s117626 [Crossref] [ Google Scholar]
11. Bajema KL, Oster AM, McGovern OL, Lindstrom S, Stenger MR, Anderson TC. Persons evaluated for 2019 novel coronavirus - United States, January 2020. MMWR Morb Mortal Wkly Rep 2020; 69(6):166-70. doi: 10.15585/mmwr.mm6906e1 [Crossref] [ Google Scholar]
12. Taghrir MH, Borazjani R, Shiraly R. COVID-19 and Iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception. Arch Iran Med 2020; 23(4):249-54. doi: 10.34172/aim.2020.06 [Crossref] [ Google Scholar]
13. Alipour A, Ghadami A, Alipour Z, Abdollahzadeh H. Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in the Iranian sample. Quarterly Journal of Health Psychology 2020; 8(32):163-75. doi: 10.30473/hpj.2020.52023.4756.[Persian] [Crossref] [ Google Scholar]
14. Ashrafi-Rizi H, Kazaempour Z. The challenges of information service related to the COVID-19 crisis. J Mil Med 2020; 22(2):207-9. doi: 10.30491/jmm.22.2.207.[Persian] [Crossref] [ Google Scholar]
15. Fallahi A, Mahdavifar N, Ghorbani A, Mehrdadian P, Mehri A, Joveini H. Public knowledge, attitude and practice regarding home quarantine to prevent COVID-19 in Sabzevar city, Iran. J Mil Med 2020; 22(6):580-8. doi: 10.30491/jmm.22.6.580.[Persian] [Crossref] [ Google Scholar]
16. Rahmanian M, Dorodchi A, Zarenezhad M, Hatami N, Javdani F, Kalani N. Knowledge, attitude and practice of students of Jahrom University of Medical Sciences to the new coronavirus (COVID-19). Med J Mashhad Univ Med Sci 2020; 63(3):2359-69. doi: 10.22038/mjms.2020.16937.[Persian] [Crossref] [ Google Scholar]
17. Nasirzadeh M, Aligol M. Assessmentof knowledge, attitude, and factors associated with the preventive behaviors of COVID-19 in Qom, Iran, in 2020. Qom Univ Med Sci J 2020; 14(7):50-7. doi: 10.29252/qums.14.7.50.[Persian] [Crossref] [ Google Scholar]
18. Peng Y, Pei C, Zheng Y, Wang J, Zhang K, Zheng Z. A cross-sectional survey of knowledge, attitude and practice associated with COVID-19 among undergraduate students in China. BMC Public Health 2020; 20(1):1292. doi: 10.1186/s12889-020-09392-z [Crossref] [ Google Scholar]
19. Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health 2020; 25(3):278-80. doi: 10.1111/tmi.13383 [Crossref] [ Google Scholar]
20. Esmaeili Dolabinejad SH, Safa M, Ghasem Boroujerdi F, Hajizadeh F, Mirabzadeh Ardekani B. Incidence of post-traumatic stress disorder after COVID-19 among medical staff of Masih Daneshvari hospital. J Iran Med Council 2020; 38(1):27-33. [ Google Scholar]
21. Fathi A, Sadeghi S, Rostami H, Jafar Pour N. The role of psychological characteristics related to mental security in corona anxiety and social stigma experience after the first wave of the COVID-19 epidemic in students. J Police Med 2020; 9(4):203-10. doi: 10.30505/9.4.4.[Persian] [Crossref] [ Google Scholar]
22. Qian M, Wu Q, Wu P, Hou Z, Liang Y, Cowling BJ, et al. Psychological responses, behavioral changes and public perceptions during the early phase of the COVID-19 outbreak in China: a population based cross-sectional survey. medRxiv. 2020. 10.1101/2020.02.18.20024448
23. Bagherian-Sararoudi R, Alipour A, Mirahmadi B. Health psychology and coronavirus pandemic crisis (COVID-19): a review study. J Isfahan Med Sch 2020; 38(570):216-26. doi: 10.22122/jims.v38i570.12962.[Persian] [Crossref] [ Google Scholar]
24. Shahyad S, Mohammadi MT. Psychological impacts of COVID-19 outbreak on mental health status of society individuals: a narrative review. J Mil Med 2020; 22(2):184-92. doi: 10.30491/jmm.22.2.184.[Persian] [Crossref] [ Google Scholar]