At the beginning of the COVID-19 outbreak in Iran, adequate measures were recommended and taken by the health system to control this epidemic. These interventions can be classified into three main parts: 1) Measures to change the health behaviors of the community and improve self-care; 2) Social distance plans; and 3) Active screening, finding patients, and isolating COVID-19 cases, which were not wholly fulfilled.
These interventions caused Iran to have acceptable success in the relative control of the first wave of the COVID-19 for several weeks. Our results showed that despite the efforts made, due to the limited evidence and scientific controversies, severe sanctions, the insufficient preparedness of society and the health system, lack of a plan for risk communication and community engagement, and after an early reopening, challenges arose in the management of the disease and the number of deaths and hospitalized people has increased for several times. The challenges explored by the study were classified into six main categories: the limited evidence and scientific controversies, inadequate attention to political, social, cultural, and economic issues and community involvement, burnout and sustained workload of health care workers, improper management of the resources and equipment, lack of updated and agreed guidelines for contact tracing and patient flow, and long-lasting community mental health problems and shortcomings in the support of vulnerable groups by the society.
The nature of the COVID-19 and the way(s) it had spread globally are still unknown, which has led to the rapid spread of the disease in different countries. The transmission potential in asymptomatic, symptomatic, mild, and severe cases remains unknown. In some cases of COVID-19, we face inconsistencies between laboratory diagnosis and clinical and radiographic findings. In line with this part of the results, some studies have focused on the unknown nature of the virus and its complex etiologies [16, 17].
In the early onset of a pandemic, there were discrepancies in the recommendations from health authorities, such as the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) [18]. The understanding of human, environmental, and animal contributions to the pandemic was poor. Several methods and medications have been recommended for the treatment of the disease [19,20,21]. In line with this study, in the American community, scientific uncertainty has been an influential factor in adherence to preventive measures by the public population [22]. Contradictions in scientific evidence and media news have also confused health care providers, and as a challenging issue, it has caused people to distrust health advice. Scientific uncertainty about the COVID-19 pandemic has caused ambiguity aversion, cognitive bias, and emotional reactions in the community [23].
The political, social, cultural, and economic status of society was recognized as an influential factor. Social and religious norms, especially in traditional societies, affect the level of exposure of people. The existence of religious and traditional ceremonies that are accompanied by crowds has been an influential factor, and these aggregations have made social distancing measures more difficult [24, 25]. The lack of sufficient financial support and national protection program from the Iranian government to the people during quarantine have made it impossible for most of the people to comply with quarantine and continue their business at the community level. This has made it impossible to control the disease because social distancing and reduced exposure, which are essential principles of reducing the risk of the disease, have become virtually impossible [25].
In some cases, some people due to poor economic conditions have not been able to provide disinfectants and masks, making it impossible to break the chain of infection. During the pandemic, different countries, based on their cultural needs and financial ability, have used different strategies and programs to control the disease. In India, the announcement of a nationwide home quarantine for 3 weeks from March 26, 2020, and the help of police forces to prevent people from leaving their homes, closing cultural and religious centers, stopping the tourism industry, and holding some popular Indian sports, such as cricket without spectators were some actions to control the disease [26]. Egypt also closed its borders and canceled international flights until April 23, 2020, closed schools, universities, sports clubs, restaurants, and cultural venues, suspended cultural and artistic activities, mosques and churches, banned collective activities, and the holding of Iftar ceremonies during the month of Ramadan, and released eligible prisoners to prevent the spread of the disease in the country [27]. The implementation of the quarantine program and its extension until the control of the disease, the performance of the social distance plan, home-to-home screening of people by health personnel, and the prohibition of public gatherings were other programs of this country [28]. The extent and quality of implementing such control programs; however, depend entirely on factors, such as the economic status of the governments and the extent, to which they support businesses affected by the disease [29, 30].
The intensive work of health care providers during COVID-19 physically and emotionally has made them exhausted [31]. Adequate, trained, experienced, responsible, and accountable staff plays an essential role in achieving the health system’s goals. A recent study in Iran showed that in terms of the subscale score of NASA-TLX, nurses obtained higher scores in mental pressure, physical pressure, time pressure (temporal), and frustration compared to other jobs. Moreover, nurses had significantly more workloads compared to other jobs [32]. Health care workers need to be motivated to provide quality services to the community. Sometimes, due to the lack of evidence and unrealistic self-confidence, health care workers neglect proper personal protective equipment (PPE), which should be monitored and supported by the health system. It is necessary to prepare a database of employees of the health system, retirees, and volunteers and organize them in alternative relief teams.
In this regard, Brazil has listed the benefits of official employees and employers from the short-term work programs supported by the government and unemployment insurance and payment for the first 15 days of sick leave to the employees who have tested positive for COVID-19. India has also allocated medical insurance for health care providers [33]. In Germany, DBfK – Bundesverband has a cooperation with the Federal Chamber of Psychotherapists to provide telephone counseling services to nurses free of charge. In Taiwan, nurses who have taken care of suspected or confirmed cases of COVID-19 may are provided with three and 14 days of paid leave, respectively [34].
Improper management of resources and equipment was found to be one of the most effective barriers to control COVID-19 in this study. Several studies have also shown the importance of supply chain impact and resource scarcity [35,36,37].
Equipment, such as PPE, ventilators, oxygen, and diagnostic kits should be available to control the disease [38]. Providing the necessary equipment in an emergency by making changes to upstream rules, developing guidelines, and transparent processes for the strategic supply chain is essential to deal with COVID19. Preventing the spread of infection at the community level and among health care providers relies on the use of PPE. This equipment should be readily available to the public to maximize its efficiency. Sometimes disruption in the supply chain of equipment used by people and health centers has led to the spread of the disease and consequently, increased demand, and eventually, this defective cycle has led to more shortage of equipment and further spread of the disease [36, 39, 40].
Contact tracing is an essential control measure to break the chains of COVID-19 transmission [41]. Because COVID-19 is highly variable and is asymptomatic in many nonspecific individuals, there is a need to advance the contact tracing to prevent further transmission [42]. Action based on a coherent protocol and guideline that includes all stages of screening, contact tracing, patient follow-up, treatment, and rehabilitation of patients is a fundamental principle in the comprehensive control and management of the pandemic. of the agreed guidelines for contact tracing and patient flow were not comprehensive [43,44,45]. The lack of an integrated and updated contact tracking system in Iran sometimes has caused an asymptomatic person to be left in the community, despite a positive test result. In some cases, family or co-workers are unaware that the person is a carrier. Contact tracking in China has been a fundamental principle in disease control [46, 47]. Covid-19 pandemic has been associated with countless stressors [48]. In low-income economies or those with no adequate government support, these tensions were excessive. The emergence of mental health problems was one of the main manifestations of these stressors. Depressive and anxiety disorders are the most common disorders seen during the pandemic period [49,50,51]. During the COVID-19 pandemic in brazil, anxiety and depressive symptoms increased 7.4 and 6.6 times, respectively [52]. Social inequality in Iran has led to more health and economic consequences for people during the COVID-19 outbreak [25, 53, 54]. People with poor economic status are more likely to experience the devastating consequences of the COVID-19 pandemic compared to others [55].
Finally, to manage the next wave of the disease, it is recommended to make a clear decision on when to reopen educational centers, monitoring the implementation of social distancing protocols, establishing more strict and serious rules for traffic restrictions, quarantine of contacted and vulnerable people, real-time exchange of information with establishing a trustable communication with the people to educate and accompany them for quarantine and social distancing. Providing appropriate and timely social support for vulnerable groups can decrease the number of patients and deaths. Supporting the country to procure vaccines at least for vulnerable groups by the international community can help the health system to manage the next coming waves or peaks.
Limitations
Some limitations should be considered when interpreting the results of this study. The main limitation of this study like other qualitative studies is the lack of generalizability of the results, which is related to the nature and philosophical assumptions of the qualitative paradigm, which our study is not an exception. Because of the pandemic, it was not possible to do face-to-face interviews, which could help to explore more in-depth experiences of the study participants and probe unclear points of view. Moreover, some health care workers and policymakers were reluctant to participate in the study and share their experiences, and finally, some related reports were not available for analysis. To overcome these limitations, we tried to use the triangulation approach for data gathering, including FGD, in-depth individual interviews and document analysis, and selecting participants with maximum diversity of experiences.
