|Year : 2022 | Volume
| Issue : 1 | Page : 129
The Iranian corona stress study: Psychological impacts of COVID-19 pandemic in an Iranian population
Sadegh Sabouhi1, Atefeh Vaezi2, Mohammad Reza Sharbafchi3, Amanda Aerni4, Dorothee Bentz4, David Coynel4, Dominique de Quervain4, Bernhard Fehlmann4, Virginie Freytag4, Christiane Gerhards4, Andreas Papassotiropoulos4, Nathalie Schicktanz4, Thomas Schlitt4, Anja Zimmer4, Priska Zuber4, Ehssan Amini4
1 Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
2 Cancer Prevention Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Transfaculty Research Platform Molecular and Cognitive Neurosciences, Faculty of Psychology and Medical Faculty, University of Basel, Basel, Switzerland
|Date of Submission||20-Jun-2021|
|Date of Acceptance||31-Jan-2022|
|Date of Web Publication||11-Oct-2022|
Transfaculty Research Platform Molecular and Cognitive Neurosciences, Faculty of Psychology and Medical Faculty, University of Basel, Basel
Source of Support: None, Conflict of Interest: None
Background: To assess the psychological consequences of changes during the coronavirus 2019 (COVID-19) pandemic in the Iranian population. Methods: We performed an anonymous online survey in the first 3 weeks of March 2020. Individuals older than 14 who could read Persian, and lived in Iran, were eligible for the study. The participants had to rate their stress levels and depressive symptoms (using a nine-item Patient Health Questionnaire PHQ-9) during the last 2 weeks and before the pandemic retrospectively. The changes in the psychological measurements and their association with the sociodemographic factors and burdens due to confinement were assessed. Results: Overall, among the 3,210 subjects who participated in our study, both the stress levels and average depression scores increased. However, about 23% of the subjects reported a decrease in their stress levels. The burden of childcare, restrictions in private life, and thoughts about the future were positively correlated with the changes in the stress levels and depression scores (|r| > 0.15). However, feeling relieved in the pandemic condition, and enjoying more family time were associated with less change in the stress and depression scores. Being religious (odds ratio [OR] [CI]: 1.5 [1.3-1-8]) and older age (OR [CI]: 2.9 [1.8–4.6] for >55 years old) were identified as the resilience factors, whereas being a student (OR [CI]: 2.1 [1.6;2.7]), seeking a job (OR [CI]: 2.6 [1.8;3.9]), and history of a psychiatric disorder (OR [CI]: 3.2 [2.6;4]) were identified as the risk factors for depression. Conclusions: The stress levels and depressive symptoms have increased during the COVID-19 pandemic and this increase is related to different social and personal burdens due to the confinement conditions.
Keywords: COVID-19, depression, epidemiology, psychological, stress
|How to cite this article:|
Sabouhi S, Vaezi A, Sharbafchi MR, Aerni A, Bentz D, Coynel D, Quervain Dd, Fehlmann B, Freytag V, Gerhards C, Papassotiropoulos A, Schicktanz N, Schlitt T, Zimmer A, Zuber P, Amini E. The Iranian corona stress study: Psychological impacts of COVID-19 pandemic in an Iranian population. Int J Prev Med 2022;13:129
|How to cite this URL:|
Sabouhi S, Vaezi A, Sharbafchi MR, Aerni A, Bentz D, Coynel D, Quervain Dd, Fehlmann B, Freytag V, Gerhards C, Papassotiropoulos A, Schicktanz N, Schlitt T, Zimmer A, Zuber P, Amini E. The Iranian corona stress study: Psychological impacts of COVID-19 pandemic in an Iranian population. Int J Prev Med [serial online] 2022 [cited 2022 Dec 9];13:129. Available from: https://www.ijpvmjournal.net/text.asp?2022/13/1/129/358322
| Introduction|| |
In the last days of 2019, an outbreak of coronavirus 2019 (COVID-19) was announced in Wuhan, China. Soon, the disease spread all over the world, and a few months later, on March 11, the World Health Organization (WHO) announced a pandemic crisis. Considering the lack of vaccination or treatment against the virus, and its fast rate of dissemination, many countries applied different levels of social restrictions to control the pandemic. These restrictions, confinement strategies in particular, along with the pandemic itself may cause a negative psychological impact on the societies. Acknowledging this, a position paper published in The Lancet Psychiatry explored the psychological, social, and neuroscientific effects of this situation. The authors of this paper stated an urge to gather data on the mental health consequences of the COVID-19 pandemic. In this regard, Luo et al. used data from 17 countries and reported a pooled prevalence of 33% for anxiety and 28% for depression during the pandemic, which is assumed to be higher in comparison with the situation before the pandemic. Iran, with a total population of about 84 million people, is one of the countries seriously impacted by this outbreak (95,646 residents tested positive, 1,135 cases/million), and 6,091 deaths linked to COVID-19 (as of May 1, 2020) is no exception in this scenario. According to a study conducted during the last 2 weeks of March 2020, 68% of the Iranian participants reported moderate-to-severe anxiety levels based on a six-item version of the State-Trait Anxiety Inventory (STAI-6). Facing stressful situations can also trigger an adaptive stress response on an individual and a social level, which may lead to positive psychological effects. For example, a study after the first Severe acute respiratory syndrome (SARS) epidemic in Hong Kong reported that about 65% of the participants cared more about their mental health, which in turn correlated with a decreased likelihood of negative mental health consequences such as post-traumatic stress disorder. It is of paramount importance to understand the impact of COVID-19 on mental health and to gain insight into the risk and resilience factors to effectively tackle the rising public health issues from COVID-19 and probable subsequent outbreaks. This knowledge is crucial to successfully adapt the current mental health services infrastructures and policies. In the Iranian Corona Stress Study in conjunction with the Swiss Corona Stress Study, we investigated changes in the stress levels and depression scores in response to the COVID-19 outbreak and subsequent confinement policies. Furthermore, the potential risk and resilience factors concerning the development of depressive symptoms were investigated.
| Methods|| |
Study design and participants
To assess the impact of COVID-19 and countermeasures on stress and depression levels, we conducted a cross-sectional nationwide study, based on a fully anonymous online survey. Each individual participated in the study at a single time point. The participants were asked to answer the questions based on their current situation or retrospectively based on their condition before the pandemic when applicable (i.e., questions about physical activity, stress levels, and depressive symptoms before the pandemic). The survey went online on May 1 (70 days since the first case was reported in Iran) and was accessible until May 25. On average, there were 1,723 new cases/day and 57 deaths/day in this period. Regarding restrictions, the Iranian government gradually lifted the lockdown measures during the survey period.
The survey was publicized using media releases by the Isfahan University of Medical Sciences, social media (i.e., WhatsApp, Telegram, Instagram, Twitter), and interviews on online news websites. The individuals who were older than 14 years, could read Persian, and lived in Iran during the study period were eligible for the study.
Consent, procedure, and outcomes
Informed consent was obtained from all participants on the first webpage of the survey. On this page, the objectives of the study, its procedure, anonymity, and confidentiality terms were explained. By declaring informed consent at the bottom of the page, the participants were directed to the survey. On average, it took 15 min to fill out the survey. In the end, the participants received recommendations respecting mental health well-being and stress management such as performing physical activities or mindfulness exercises.
Survey translation and measurements
The design of the Iranian Stress Study online survey was guided by the Swiss Corona Stress Study survey design. The survey consists of three sections covering sociodemographic factors, burdens due to the pandemic and confinement, and psychological measurements (i.e., stress and depression). In the first two sections of the questionnaire, we collected the sociodemographic and burden-related data (for more detailed information, the survey is attached in Online resources). Afterward, the following outcomes of interest were assessed: the stress levels and depressive symptoms before the COVID-19 pandemic (i.e., February 5–19, 2020, rated retrospectively) and during the past 2 weeks of the lockdown (counted from the date the survey was filled out). The stress levels were assessed using a single six-point Likert scale question ranging from 0 (not at all) to 5 (extremely strong). The depressive scores were assessed by the Patient Health Questionnaire 9 (PHQ-9), a nine-item self-administered questionnaire to screen for the presence and severity of depression. Each item is scored based on a Likert system from not at all (0 points) to nearly every day (3 points). The total score of PHQ-9 is ranged between 0 and 27. Based on the total scores, the participants were categorized as having no or minimal depression (0–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19), and severe depression (20–27).
We used an existing Persian translation of the PHQ-9 (see for English and for the Persian version). The remaining items of the survey were translated from German to Persian, then face validity and cultural adaptation of the Persian version were checked and approved by an expert panel. Finally, all the items were translated back to German by the Basel University Language Center and reviewed by the Swiss study team to confirm that the Iranian and Swiss Corona Stress Study questionnaires are equivalent.
The authors assert that all the procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human subjects/patients were approved by the Ethics Committee of the Isfahan University of Medical Sciences, Iran (IR.MUI.MED.REC.1399.069). In respect to anonymity, only the day of participation was recorded in the survey, while the IP addresses and timestamps were not recorded.
We used R version 3.6.2 for data analysis. We applied linear models in combination with Analysis of variance (ANOVA) for nominal variables, Spearman's rank correlations for ordinal variables, and Pearson correlations for interval variables. For stress and depression, a difference score was calculated by subtracting the score before the pandemic from the score during the pandemic (we refer to the difference score as the change in stress or depression, respectively). Therefore, positive values indicate an increase in the stress/depression scores during the pandemic as compared to before the outbreak. The statistical models consisted of one dependent variable (one of the main outcome variables) and one independent variable. For linear models, the strength of the relationships was obtained by extracting the correlation value 'r' from each corresponding linear model (i.e., normalized regression coefficient). We only report relationships with at least a small effect size (|r| ≥ 0.1). The change in the number of participants reporting moderately severe to severe depression symptoms (PHQ-9 score ≥15) before and during the pandemic was further compared using the McNemar's Chi-square test.
Risk and resilience factors analysis
We defined 'vulnerable' individuals as those reporting PHQ scores ≥15 during the pandemic (corresponding to 'moderately severe' and 'severe' categories) while having a PHQ score <15 before the pandemic. 'Resilient' subjects were defined as participants reporting PHQ scores ≤4 ('None-Minimal') both before and during the pandemic. To identify the risk and resilience factors, we first applied the Chi-square tests comparing the distribution of demographic factors between each defined subset (resilient or vulnerable) and all remaining individuals. The variables showing at least small effect sizes (Cramer's V ≥0.1) were further investigated under a logistic regression model. Only associations with an OR corresponding to at least a small effect Cohen's d [INSIDE:1] were interpreted. Marginal effects from logistic regression were obtained using the ggeffect command in the R package ggeffects. To avoid individual variable categories with low frequencies in these analyses, some demographic variables were regrouped as follows: occupational status (working in a sector affected by pandemic restrictions, working in a sector not affected by pandemic restrictions, retired or disabled, housekeeper, job seeking, student); age group (14–24, 25–34, 35–44, 45–54, ≥55); education (with a university degree, without a university degree); household (living alone, not alone). Besides, as only a small portion of the participants (N = 21) reported their sex different from 'male' or 'female', data from these participants were excluded from the final analysis to maintain statistical power. For comparing the effect of age, sex, having child (ren), religiosity, and prior psychiatric disorders history on the probability to belong to the resilient group, we evaluated the effect of each variable in the logistic regression model employing Nagelkerke pseudo-R2, comparing the full model to the model without the considered variable (only variables with Nagelkerke pseudo-R2 ≥ 0.01 were interpreted).
| Results|| |
Population and descriptive statistics
In total, data from 3,210 participants were included in the final analysis. Although the participants took part in the study from all 31 states of the country, most participants were from Isfahan (37.4%) and Tehran (23.3%), which are the third and the first most populated provinces, respectively, and contribute to approximately 23% of Iran's population.
The mean age of the participants was 34.1 (SD = 10.9) and 63.8% were females (according to the last Iranian Population and Housing Census, the Iranian population had a mean age of 31.1 years and male to female ratio of 1.03 as of the year 2016), 4.5% lived alone and 45.4% had one or several children. As per the educational level, 74.7% had a degree in higher education. The high school and university students comprised 26.8% of the participants. Regarding occupational status, 7.2% of the study population was seeking a job, while 48.8% reported having a job. Among those with a job, 19.0% worked in sectors that were affected by reduced working hours or closure due to the government's policy. Under religiosity, 54.1% of the participants reported being religious.
Concerning the COVID-19 disease, 86.8% of the participants had been symptom-free and not tested for the disease, 68.8% of the participants knew someone with the COVID-19 disease personally, and 45.8% knew someone deceased because of it.
Regarding the pre-existing health conditions, 604 (18.8%) subjects reported having a medical history of a chronic physical condition and 31.7% had a history of psychiatric disorder/disease (the most prevalent being depression [20.1%] and anxiety disorders [16.3%]). For further details, see [Supplementary Table 1].
Change in stress levels
The stress levels among the participants had increased during the pandemic (difference score: mean = 0.20, median = 0, SD = 1.36; before the pandemic: mean = 2.89, median = 3, SD = 1.44; during the pandemic: mean = 3.10, median = 3, SD = 1.63, see [Figure 1]). In total, 29.9% of the participants experienced an increase in the stress levels, 47.3% reported the same level of stress both before and during the pandemic, and 22.8% had perceived less stress than before [Figure 2].
No significant correlation was observed between the change in stress levels and sociodemographic variables. The following impacts of COVID-19 restrictions show the strongest association with stress levels change: the burden of child care (r = 0.21), the burden due to thoughts about the future (r = 0.20), the burden due to living alone (r = 0.19), and limitations in personal freedom (r = 0.17). On the other hand, the change in the stress levels was negatively correlated with feeling more relieved during the pandemic (r = −0.24) as well as with confidence in overcoming the COVID-19 crisis (r = −0.16). For further details, see [Supplementary Table 2].
A positive correlation was observed between the stress levels change and the change in the depression score (r = 0.40). The stress levels were also correlated to the depression score both before (r = 0.43) and after the (r = 0.58) pandemic.
Change in depression score
On average, the total PHQ-9 score increased during the pandemic (difference score: mean = 2.45, median = 1, SD = 5.44; before the pandemic: mean = 5.41, median = 4, SD = 5.10; during the pandemic: mean = 7.86, median = 6, SD = 6.55). Overall, 54.8% of the participants reported an increase in the depression score, while 21.4% had the same score as before, and 23.8% had a lower depression score during the pandemic [Figure 3]. Based on the participants' retrospective assessment of their depressive symptoms, 191 (6.0%) of them were in the moderately severe or severely depressed category (PHQ-9 score ≥15) before the pandemic. This number almost tripled to 526 (16.4%) during the pandemic (McNemar's test P value <5.9e-57; Cohen's g = 0.38; [Figure 4]).
|Figure 4: Distribution of the depression score category before and during the pandemic|
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The depression score increased more in the participants who reported having a psychiatric disorder history (r = 0.13). Confinement impacted the depression score in several ways. The burden due to living alone (r = 0.31), the burden of childcare at home (r = 0.30), the burden due to thoughts about the future (r = 0.28), and the burden due to restrictions in spending time with others in private life (r = 0.25) are the items with the highest effect size. Changing the regularity of meals and sleeping time are also accompanied by an increase in the depression score with an effect size of r = 0.27 and r = 0.22, respectively. On the other hand, changes in the depression score negatively correlate with feeling relieved (r = −0.36) and enjoying more family time (r = −0.20) in the confinement situation. For more information see [Supplementary Table 3].
Risk factors for the development of clinically-relevant depressive symptoms during the pandemic
During the pandemic, 388 (12.1%) participants shifted from lower categories of depression (PHQ-9 score <15) to a clinically-relevant depression score (moderately severe or severe category; PHQ-9 score ≥15). To identify the potential risk factors, we compared these 'vulnerable participants' to other participants in terms of sociodemographic and medical history. Having a prior history of psychiatric disorders was more prevalent in the vulnerable participants (Cramer's V = 0.20); among the prior psychiatric disorders, history of depression (Cramer's V = 0.17), and anxiety disorder (Cramer's V = 0.16) are noteworthy. The occupational status also played a role in this group with a Cramer's V effect size of 0.15.
We included these variables in a logistic regression model and found that there are more vulnerable cases among the participants with a psychiatric disorder history (OR: 3.2, 95% CI [2.5–4]). Considering contrasts for occupational status, there was a higher risk for students and those who were seeking a job to be in the vulnerable group [Supplementary Table 4].
Resilience factors concerning the depressive symptoms
A total of 994 (31.0%) subjects have been categorized as having non or minimal depressive symptoms (PHQ-9 ≤4) both before and after the pandemic. We considered this group as the “resilient group” and compared it to all other participants in terms of sociodemographic factors and medical history. The resilient participants were significantly different from the other participants in terms of psychiatric disorder history (Cramer's V = 0.24), age group (Cramer's V = 0.20), occupational status (Cramer's V = 0.18), being religious (Cramer's V = 0.14), having child (ren) (Cramer's V = 0.13), and sex (Cramer's V = 0.11) [Supplementary Table 5].
We performed a logistic regression model with all the significant variables identified above. Only the effects of age, religiosity, and psychiatric disorder history remained significant (Nagelkerke pseudo-R2 <1%).
The logistic regression model showed that there were more resilient participants among those with no psychiatric disorder history (OR = 3.5, 95% CI [2.9–4.3]). It also indicated a higher resilience rate among those who reported being religious (OR = 1.5, 95% CI [1.3–1.8]). According to the age group, those with an age of 55 or higher showed higher resilience compared to the other age groups (OR = 2.9, 95% CI [1.8–4.6] against 35–44-year age group; [Supplementary Figure 1]).
| Discussion|| |
In this study, we assessed how the COVID-19 pandemic and following confinement strategies impacted the mental health and well-being in the Iranian population. We observed an increase in both averages of the depression scores and stress levels among the study population. This increase correlates with various burdens triggered by confinement policies and fear of the COVID-19 infection. On the other hand, enjoying more family time, feeling relieved in this period, and being confident to survive the pandemic without problem have a negative association with the changes in the average depression and stress scores. Additionally, we were able to identify several risk and resilience factors: being a student, seeking a job, and having a psychiatric disorder history are risk factors, whereas higher age, negative psychiatric disorder history, and being religious are resilience factors.
Changes in the stress levels and depression score
The stress levels and depression scores among the participants increased on average. This result is in line with most studies assessing the psycho-behavioral changes during this pandemic. In the recent studies conducted in Iran, Wong et al. reported 68% of the participants having/suffering from moderate-to-severe anxiety using the State-Trait Anxiety Inventory, while in another one, Maarefvand et al. observed an above-average mean score of stress (3.3 out of 5) in 3,787 participants. Regarding the depression scores, the same trend can be seen. In two meta-analyses, the prevalence of depression was estimated to be 23–33%, which is higher than the normal prevalence range before the pandemic., Our study supports these findings with an increase in the mean scores of depression and a 10% increase in the prevalence of moderately severe and severe depression during the pandemic crisis. Comparing this study to the Swiss Corona Stress Study, the average stress levels and depression scores before and during the pandemic were higher in the Iranian sample, but interestingly, despite all the cultural and economic differences, the changes in these scores followed the same pattern in both studies.
Considering the stressful situation of a pandemic, we expected the worsening of mental health in our participants, but to our surprise, we also found a reduction in stress and depression for a considerable number of participants in both the Iranian and Swiss populations. This might result from an adaptive stress response in these participants. This response has been seen in previous crises at both the individual and social levels. In a similar condition to the COVID-19 crisis, after the first SARS epidemic in Hong Kong in 2003, Lau et al. reported that about 60% of the subjects cared more about their families after the epidemic, over 65% of them paid more attention to their mental health, and up to 40% spent more time relaxing and exercising, and these behavioral changes were accompanied by fewer psychological problems. Notably, 23% of the participants in our study reported being highly relieved in the current situation, which might be due to a reduction of daily stressors compared to before the pandemic. Furthermore, over 18% of the participants reported enjoying the possibility of having more family time due to confinement. Both variables were negatively associated with the change in the stress levels and depression scores both in our study and in the Swiss study. Thus, it can be supposed that such a break in today's stressful life can act in favor of mental well-being, at least for some individuals.
Risk and resilience factors
Although no sociodemographic variable was observed to be associated with the stress levels change, being a student or seeking a job were identified as a risk factor in the 'vulnerable group'. Universities and schools were closed due to governmental counter measurements and many classes took place on online platforms suddenly which was a big change for the educational system. On the other hand, due to the economic effects of the pandemic, many companies and industries had to reduce their workforce, leading to a significant decrease in job opportunities and employment all over the world. These factors caused a high level of uncertainty about the future and economic concerns for students and those seeking jobs. Uncertainty is a known source of stress and the professional future being unpredictable can be an extra burden for these participants. Moreover, it was also shown in our study that both factors (e.g., economic consequences and worries about the future) were associated with a higher level of stress and depression per se. In line with this, Cao et al. reported economic worry as a risk factor to increase anxiety in a Chinese population.
Psychiatric disorder history is the only item that plays a role both as a risk and a resilience factor. It is a well-known fact that those with a positive psychiatric disorder history are more vulnerable in challenging situations. This effect was also observed in other studies assessing psychological risk factors during the COVID-19 pandemic., This highlights again the importance of excessive attention to this part of society when it comes to maintaining mental health in challenging situations.
We identified being religious as a resilience factor in our study on the Iranian population. This association was not observed in the Swiss study. In scientific literature, the relationship between religiosity and depressive symptoms is discussed controversially. However, to get a better understanding of religiosity's impact on psychosocial well-being, it should be interpreted in the context of socio-cultural aspects of the population. To our knowledge, there is no study assessing religiosity's effect on mental health among the general Iranian population, but a small number of studies assessed this association in college students, confirming a negative correlation between religiosity and depressive symptoms.
We also found that participants aged 55 or higher were more resilient than the younger ones. Reviewing recent similar studies, the results are quite controversial regarding the effect of age. In a review, studying psychological resilience to disasters, this controversy is highlighted: age is introduced to be a risk factor in some and a resilience factor in other studies. Two studies investigating the Iranian population's mental health during the COVID-19 pandemic report younger age groups to be more susceptible to stress and anxiety., The focus of these studies is on anxiety and stress, whereas the resilience factors in our study are defined based on the depression scores. Therefore, these results cannot be directly compared to each other. However, considering the high correlation between the stress levels and depression scores in our study, a common trend can be seen among all three studies: the older age groups are less affected by the COVID-19 crisis concerning stress and depression.
Strengths and limitations
In this study, we benefited from a reasonable number of participants with various sociodemographic characteristics who participated from all over the country. Various kinds of burdens due to the pandemic and confinement were included in this study, which enabled us to have a discriminatory appraisal of the sources of possible stressors. Most studies investigating the impact of COVID-19 on mental health conducted so far have compared mental health indicators with a reference population. In most cases, this reference population is different from the study's participants in terms of the sociodemographic characteristics which makes further interpretations less precise. However, in our study, by comparing the same population before and during the pandemic, we were able to have a more accurate perspective of the issue.
Despite these strengths, several limitations should be considered when interpreting data. First, our study population is not representative of the Iranian general population due to several reasons: This study was publicized and conducted on an online platform, thus, excluding people who did not have access to the Internet. It is noteworthy that this group predominantly includes people from lower socioeconomic levels and those living in rural areas and small cities. Moreover, due to sampling methods and media platforms used for advertising the survey, our participants were mostly from a higher educational level, which is not proportionate to the Iranian general population. Further, we used a single question to measure stress levels instead of a known valid questionnaire to make the survey more convenient for the participants. It should be considered that we cannot discuss concepts such as the clinical relevance of stress levels using this measurement. Finally, we cannot exclude a possible recall bias, which may have led those being more affected by the situation to report their prior state in an unrealistic manner.
The COVID-19 pandemic is not the first and will probably not be the last of its kind. In such crises, health systems focus more on immediate harms like mortality. However, psychological harms caused by the situation and policies (such as confinement) have to be considered. In this study, we tried to shed light on the psychological states and probable risk and resilience factors in Iran. Considering that our data were not completely representative of the general population, more and larger studies are still needed to be conducted. Moreover, it should be considered that most studies so far have used an online platform, and therefore, have missed a considerable part of the population with no proper access to the Internet or electronic devices. Future studies should also include this part of the population.
The data that support the findings of this study are available on request from the corresponding author (EA).
A preprint version of the study has been already published and is accessible through https://osf.io/cfgbk/. (Preprint DOI: 10.31219/osf.io/cfgbk).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to acknowledge Isfahan Student Research Committee and specifically Amir-reza Manteghinejad for designing and maintaining the Iranian Corona Stress Study website; Dr. Asad Omidi and Dr. Bita Shadbakht for their great help in survey adaptation for Iranian culture; Basel University Language Center for their help in the survey translation process; BaniShow startup and Babak Rajabi for their kind help in advertising the survey, and last but not least all participants for their time and contribution in our study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]