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Social determinants of health during and after coronavirus: a qualitative study

BMC Public Health volume 24, Article number: 283 (2024) Cite this article

Abstract

Background

Health has multiple dimensions influenced not only by individual factors but also by broader social, economic, cultural, and political structures. The widespread COVID-19 pandemic has multidimensional effects on people’s lives, which can have effects on individuals’ lifestyles after the COVID-19. This study aimed to speculate the social determinants of health during and after the COVID-19, which can lead to more effective planning for promoting community health.

Methods

The present study interviewed 21 experts in social and medical fields during four months. The sampling method was snowball. The interviews were semi-structured and administered in-person or electronic. All interviews were transcribed and analyzed according to the Brown and Clarke’s six-stage framework to extract themes.

Results

the participants were 13 males, eight experts in social field, all had PhD, 17 were academic members, and 10 were members of the Social Determinants of Health Research Center. The qualitative content analysis induced seven different social themes that affect the health which included: justice (3 Subcategories), integration (4 Subcategories), acceptance (4 Subcategories), participation (2 Subcategories), adaptation (3 Subcategories), flourishing (4 Subcategories), and cohesion (3 Subcategories).

Conclusions

According to the present study, a grand plan to cover all positive and negative social effects of COVID-19 should have at least seven different dimensions. However, the present models of effective social determinants in health do not have such comprehensiveness. Future studies may provide a proper model to be used in clinical and research fields.

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Background

Society is a group of people who live together and have various cultural, political, and economic interactions and exchanges, therefore the society has structure. Contemporary complex industrial societies and past simple societies have a common aspect: they are not simply the result of people coming together. But, each possesses its specific social structure, distinguishing them from other imagined social forms. The philosophy of social formation is based on the realization that only within a society, people can fulfill and satisfy specific fundamental needs or, at the very least, access them more easily [1]. Human societies are various interwoven factors including culture, social, economic, and politic. While these factors are distinct, they interact with each other, establishing tangible connections. The interactions of these factors can render the conditions of society critical and disordered or desirable and ideal. As creators of the constituents of human societies, humans assume various social roles, and the proper fulfillment of these roles enhances interactions within the community. Humans can effectively perform their social functions and continue their activities while they feel themselves healthy and their living environment is not disturbing their comfort. Currently, health is considered a multidimensional and multilayered phenomenon among fundamental human rights which is a necessary condition for fulfilling social roles. People can be fully active when they feel healthy and society considers them healthy. In this context, health will be categorized in the ranks of social values, and the biological variables will not be sufficing to provide a comprehensive definition of health. The World Health Organization (WHO) provided the definition of health in Geneva in 1948 that can still be used in health-related theories. This definition encompasses complete physical, mental, spiritual, and social well-being and not merely the absence of disease. For the first time in the world, this definition included social health alongside psychological and physical health. Moreover, the WHO describes differences in health status or the social determinants of health in various strata of society as inequalities. When these inequalities are avoidable, it refers to them as injustices [2].

Although the impact of social determinants of health has been recognized for centuries, the inherent and genuine interaction between social trends and health and disease has recently been raised [3]. The evidence suggests that the utmost burden of diseases and the most pronounced health inequalities in the world arise from social determinants [4]. The social conditions and determinants influencing people’s health are diverse and complex [5]. Social determinants of health can be defined as the conditions in which people are born, grow, live, work, and age, which are influenced by stronger forces such as economic factors, social policies, and political issues [6].

Social determinants of health contain the social factors that promote or weaken individuals’ health and the underlying processes of these factors [7]. The importance of social health is such that individuals who possess it can better cope with problems arising from fulfilling their primary social roles [8]. It must be acknowledged that communicable diseases are becoming more of a social problem than just healthcare issues [9]. Therefore, professionals should particularly consider the differences in social and economic factors and their impact on individuals’ health in emergency health conditions [10]; so that the disadvantaged population does not endure a heavier burden of health emergency as for example pandemics. It should be noted that people from low socioeconomic backgrounds experience worse health conditions and shorter lifespans than those counterparts from higher socioeconomic backgrounds [11].

One of the most significant pandemics in human history is the COVID-19 that has rapidly spread with a high mortality rate. The virus was first discovered in China in late 2019 and has since become one of the most challenging human trials in modern history. Studies have demonstrated the impact of this pandemic on human social factors. As the number of confirmed cases of COVID-19 continue to rise, the virus with negative effects on health systems and increasing the fatal rate has shaken the foundations of the global economy and led to sustainable geopolitical changes [12]. This infectious disease threatens the physical health of societies and, in some cases, leads to fatalities. It also affects both physical and mental determinants on health because it generates uncertainty and confusion among people. Consequently, it imposes unbearable psychological pressure, such as stress, anxiety, depression, and grief, on affected societies [13]. The emergence of a public health crisis like the COVID-19 pandemic can significantly represent roles of social determinants of health on contagious, spreading the infection, and the impact of the pandemic on social health factors. This health crisis even penetrates people’s living conditions and lifestyles to the extent that in-depth changes occur even after the pandemic ends. It is essential to acknowledge that lifestyle is directly related to people’s health [5], therefore, special considerations should be given to the changes of people’s lifestyles after the COVID-19 pandemic ends.

The review of the literature has revealed that most of the studies have considered the medical aspect of this pandemic such as background, prevention, symptoms, risks, complications, treatment, and the psychological and psychiatric effects of the disease [14,15,16]. Other studies in this field explored disease patterns based on social factors in an infected area [16], effects of bioenvironmental, social, and political approaches on the performance of some centers during the COVID-19 pandemic [17], and understanding of the disease and some social factors such as perceived social support [18]. To the best knowledge of the authors, there is not any study considered the social determinants of health comprehensively. While such study may enlighten the professionals of some hidden factors that could change the medical and health outcomes.

Considering the paucity that we felt in the studies, the research team decided to conduct a qualitative study to speculate the social determinants of health during and after the COVID-19. The main objective was to identify and analyze the various social factors impacting health and to recognize their subgroups. By determining these factors, this study may provide essential information to social and healthcare policymakers. They will be able to use this information in strategic planning to enhance society’s lifestyle and overall health indicators during and after the pandemic of COVID-19. The research team hypothesized that all social determinants on health are interacting with each other and a comprehensive perspective regarding the social determinants of health will provide effective solutions for improving community health.

Materials and methods

The present study had qualitative design. Qualitative research involves studying clients in their natural environments and interpreting phenomena based on the meanings that people attribute to them. In qualitative approach, often conducted through interviews, the aim is to obtain the perspectives and interpretations of the study participants and represent and convey these findings [19]. Regarding to the aim of the present study, the research team chose this method to examine and identify the social determinants of health during and after COVID-19. Therefore, the present study can be considered as a thematic analysis type. Thematic analysis is a method for analyzing qualitative data and is one of the cluster methods that focus on identifying patterns of meaning within a dataset. Unlike many other qualitative methods, thematic analysis is not tied to a specific epistemological or theoretical perspective, making it a flexible approach. The goal of thematic analysis is to identify themes that are patterns in the important and interesting data for the researcher. Braun and Clarke introduced a six-stage framework for conducting thematic analysis, which includes familiarizing oneself with data, generating initial codes, searching for themes, reviewing themes, defining themes, and writing the final analysis [20, 21]. Since we chose to have thematic analysis, the research team followed Brown and Clarke’s six-stage framework. In diagram 1, the steps toward aim of the present study have been displayed.

Diagram 1
figure 1

The conceptual framework of the qualitative study of determinants of social factors affecting health during and after Covid-19

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Design questions

With the aim of doing the study, the research team started by review of the related literature and upstream documents. In this review, factors, components, and indices of social determinants on health were identified and proper questions to be conducted in interviews were designed. three questions (and exploratory ones), as outlined in Table 1, were used in this study.

Table 1 Semi-structured interview guide questions
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Interviews

To enrich and strengthen the data obtained from the literature, and to develop the conceptual model, expert opinions and specialists’ insights were collected through semi-structured interviews. The sampling method was started by purposeful and non-random (according to Teddlie & Tashakkori, 2023) [21]. To continue the study, the research team undertook the snowball method. Firstly, the research team started interviewing those experts who have been well-known in this field and had all inclusion criteria (to be familiar with Covid-19 and their previous research on the impact of social factors on the occurrence of disease). When the interview was finished, the interviewer asked each interviewee to introduce any other expert that had the mentioned inclusion criteria. Each interview was transcribed immediately by the interviewer. In both groups (scientific and clinical), the interviews were continued until in the last 2–3 interviews no further information was obtained (data/theoretical saturation). The statistical population were two groups. The first group (scientific) was those experts and specialists who had sufficient knowledge in the field of health, i.e., authored books or articles related to prevention, treatment, or health promotion, or those with academic qualifications in this field. The second group (clinical) included individuals who were active in the health field i.e., familiar with health issues, actively engaged in education, research, healthcare, or related fields for the preservation and promotion of health (details of each participant have been presented in Table 2).

Table 2 A synoptic table presenting the panel
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All interviews were administered nationally (including Tehran, Semnan, Khorasan, Orumiyeh, Kashan), between November 2022 and February 2023. To make it possible, the interviewees were able to choose their mode: face-to-face or online (through social messaging apps). Each interview lasted for 45 to 60 min. In face-to-face interviews, the interviewer took notes and recorded whole sessions to be able to do a recheck and have a full transcription. However, for those who chose online mode, the interviewees wrote their answers and sent them back to the interviewer. In both conditions, the interviewers contacted the participants when any response was vague or problematic. Additionally, if a specific point was raised by a participant, in next interview, the interviewer would emphasize on that point to get a clearer response [22].

Braun and Clarke’s six-stage framework

When each interview was transcribed by the interviewer, the six-stage of thematic analysis was started. Main parts of this process were identifying and encoding semantic units (Basic level), classifying the units into broader categories (Organizing level), and finally, extracting main themes (Comprehensive level). The researchers conducted essential informant confirmations, expert reviews, and document analysis to enhance the data’s reliability. The researcher used manual coding to analyze data. Redundant and excessive codes were removed, and the process continued until broader categories and extensive components related to health were identified.

Evaluation of study rigor

The research team employed various methods to achieve credibility, dependability, confirmability, transferability, and authenticity. These included member checks, granting participants the opportunity to review and validate or remove interview data, assessing how coding was performed by the research team and individuals familiar with the research methodology (external check), obtaining informed consent, and providing transparent explanations of the research process for all participants, and providing rich data descriptions to ensure a clear understanding of the research process. A sampling method with maximum diversity was also used, and prolonged engagement in the field was maintained. The researcher tried to be accurate in sampling, documenting, data collecting and analyzing, and using the participant-feedback method in addition to quality criterion to make the obtained data valid and reliable.

Investigator triangulation

To evaluate the credibility of the findings, three people including a pulmonologist, an internal specialist, and a person active in social science studies transcribed the same 20% of all interviews independently. The main researcher asked them to analyze and interpret their transcriptions according to the Braun and Clarke’s approach without prior discussion or collaboration among them. The research team compared all transcriptions, resolved the discrepancies, and reached to a consensus through point-by-point method and reached approximately 90% of agreement among analyzers.

Results

This study aimed to find social determinants of health during and after Covid-19 through a qualitative approach. Interviews were running with 21 experts with an average age of 44 years (eight were female). Eight had clinical experiences, 17 were academic staffs, and 18 married people. The thematic analysis of the transcriptions induced 10 themes, 33 subcategories, and 132 semantic units.

Q1: dimensions and components of the social determinants of health

All experts answered this question in full agreement that the conceptual framework of influential factors on health, as expressed by the WHO, is the best model to be used in evaluation of social determinants on health. In their opinions, the social concept mentioned in the WHO’s definition of health could be impressed by at least 10 different themes: (1) Individual factors, (2) Biological factors, (3) Social justice, (4) Social integration, (5) Social acceptance, (6) Social participation, (7) Social adaptation, (8) Social prosperity, (9) Social solidarity, and (10) Spiritual factors.

Individual and biological factors

Although in WHO’s definition of health, these factors have their special positions, most of experts in this study believed that age, gender, genetic factors, and mental status impact one’s social determinants on health. Yet, one expert has emphasized the effect of health literacy and media literacy on social determinants on health. They elaborated the mental status factors in different concepts such as the influence of self-efficacy, personality type, interpersonal relationships, and emotional well-being. Besides, the lifestyle of the people could significantly affect their health; even if all conditions for health were met, but then people were not following a healthy lifestyle, their health could still be in danger. Furthermore, most experts believe in the influence of biological factors, such as environmental conditions, on individuals’ health.

Social Justice

This themes was extracted from three different policies: economic, government, and societal general rules and regulations. In Table 3, details of the basic units, organizing levels, and comprehensive theme have been presented.

Table 3 Explanation of the theme of social justice affecting health
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Social Integration

The second theme was social integration which was a consolidation of four different organizers (level 2) as displayed in Table 4. Experts (1, 9, and 11) said “the acceptance of the social norms, avoiding of breaking the law, and committed to obey the rules are effective in social health; social health is necessary for the health of the members of the society”. Experts 3 to 7 expressed: “family making is the cause of social health”. Even, expert 11 believed: “being employed is effective in health”.

Table 4 Explanation of the theme of social integration among social factors affecting health
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Social Acceptance and Participation

According to the experts, “social judgment, whether in the form of acceptance, rejection, or neutrality, significantly impacts people’s health”. Also, “conformity and social influence of people has an effect on the health of society and consequently on the people’s health”. “The participation of individuals in society, both formally and informally, reflects the health and dynamism of the community”. In Table 5, the thematic analysis regarding these two themes have been displayed.

Table 5 Explanation of the theme of acceptance and social participation of social factors affecting health
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Social Adaptation

To reach this theme, the basic units went through three levels of organizing (Table 6). Ps 2, 5 and 8 said: “Crime, aggression, superstitions, irresponsibility, breaking the law and people stress in society are the marks of lack of health in the society”. P13 said: “Charitable donations, being responsible, and law-abiding are those preventive factors that protect the health in the society”.

Table 6 Explanation of the theme of social adaptation of social factors affecting health
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Social Flourishing

A society would flourish if “social happiness and vitality” according to Ps 3, 7, and 14 in addition to “meritocracy, the development of people’s self-esteem, and people’s welfare” Ps 10, 16 and 17 as well as “a sense of community security” based on the experts’ opinions existed. In Table 7, this specific theme along with its subcategories and basic units have been presented.

Table 7 Explanation of the Theme of social Flourishing from Social Factors Affecting Health
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Social Cohesion

P9 said: “the unity among people and the attraction between the society members are the prerequisites of society health”. In Table 8, this specific theme along with its subcategories and basic units have been presented.

Table 8 Explanation of the theme of social Cohesion among social factors affecting health
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Spiritual Factors

Considering the WHO’s definition of health, the spiritual aspect should also be considered as all experts said. Ps 3, 10, 14, 19 and 20 believed that “spiritual and religious components have an important role in people’s health”. P20 believed: “religious and spiritual aspects are subcategories of society’s culture and play roles in people’s health”.

Q2

The effective role of social determinants of health during COVID-19.

Most of the experts considered the factors affecting the health of the society during the outbreak of the Corona virus to be similar to the factors affecting health before the pandemic, however, they deemed social factors much more critical during the pandemic. They expressed the influence of appropriate social behavior, without stress and anxiety, a healthy diet, using helpful social media, and physical exercise in controlling the spread of COVID-19 disease (P 1, 2, and 3). P6, while emphasizing the prominent role of social factors in mitigating the pandemic and reducing its casualties, pointed out health education through media, legally mandated physical distancing, and mask-wearing as three main indices contributing to the success of societies in controlling the COVID-19 pandemic, which are all social determinants on health.

Also, some experts considered the pandemic of Corona virus effective on social factors and mentioned that a two-way relationship has been established during the pandemic of Corona virus between the disease and social determinants on health. This relationship could have positive effects including leading to increased empathy, compassion, and cooperative approaches among people; a surge in spiritual tendencies; an increase in respecting each other’s rights; evolution in attitudes of art communities and social science theorists; improvement in media literacy; enhancement of health literacy; an increase in preventive acts, and justifiable therapeutic support. On the other hand, it could have adverse effects, causing public fear; increased hopelessness, family and societal conflicts, and unemployment rate; reduced income, leisure activities, physical exercise, and social interactions; and dissemination of falsehoods. These positive and negative societal effects may result in changes in social factors, once again affecting people’s health (quoted by P 4,5, 6, 9, 11, 18, and 21).

Q3

The effective role of social determinants of health after COVID-19.

All experts referred to the specific impact of social determinants of health after COVID-19. P1 said “those who suffered more damages during the pandemic, such as those who lost their jobs, homes, or loved ones, or a decrease in income, are at risk of deteriorating health”. P3 mentioned some achievements would be perceived after COVID-19: “Health proceedings will continue. The use of new technology will persist, leading to reduced traffic, pollution, and road hazards. A transformation in economy, culture, and communications, which is not similar to the pre-COVID era, and these changes will give rise to new social factors affecting health. Individuals will focus on self-care and care for others.”

P4 emphasized: “According to the conditions and extent of crisis management during the pandemic, various psychological, communication, and educational abnormalities have emerged, which will continue for years. These [abnormalities] should be considered as social factors that can compromise health, and appropriate strategies should be devised to tackle them”. P6 said: “initial documentation of the experiences of the Corona era and turning them into artistic and literary works can make these experiences last, and the cooperation of the Ministry of Health and cultural institutions can create a fundamental basis for the introduction of social determinants that affect health in the society. It [the fundamental basis] causes the optimal management of all capacities to achieve justice in health and the mutation of these components”. According to P11 “if social, cultural, and economic factors are optimal, society can more easily return to the pre-COVID conditions”.

Discussion

Social well-being refers to the ability to interact with others and the environment to establish satisfying interpersonal relationships. Capabilities such as sincere communication with others and managing conflicts in a proper way and ethically over an appropriate and acceptable period of time are among the indicators of social well-being. Respecting others, taking responsibility for the community, and being prepared to spend personal resources for the society and engage in healthy and balanced interactions with others (in a way that neither we nor others are exploited) are considered subcategories of social health. The present study, based on the expert opinions, identified seven social determinants on health, that interacting with personal factors additionally to spiritual factors. Those seven social determinants social justice, social integration, social acceptance, social participation, social adaptation, social flourishing, and social cohesion. Our findings were partially in line with the model presented by Keyes (1998). Keyes presented a multidimensional model for social health, which included social coherence, social acceptance, social contribution, social adaptation, and social actualization [23]. We found two more dimensions that Keyes’ model did not include: social justice and social cohesion. This difference might be a result of the methodology and the concept that each study searched for. Our study had qualitative design assigned to find social determinants of health during and after Covid-19; while Keyes tried to develop a proper scale to evaluate social well-being. It seems the differences of terms in these two studies are superficial, since the definitions and concepts that they include are similar.

The bio and psycho factors of each person can be affected during and after COVID-19, as the experts highlighted in the present study. This is in concert with findings reported by different studies [24,25,26,27,28]. For example, Sher (2021) reported that many COVID-19 survivors experience persistent physical symptoms such as cough, fatigue, dyspnea and pain after recovering from their initial illness; they also experience persistent psychiatric symptoms such as depression, anxiety, and post-traumatic symptoms as well as neurological impairment including anosmia, ageusia, dizziness, headache and seizure. He hypothesized that these symptoms may increase the possibility of suicide or suicidal ideation [24]. Obviously, in a society that a large number of people were and are struggling with bio-psycho symptoms of COVID-19, the social aspect of their lives would be in danger as well (as Einvik and colleagues showed in 2021) [29].

The present study indicated that during and after Covid-19, another dimension that has effects on social health is spiritual factors. These factors have been considered as an important dimension of health [30]. We found spiritual attitudes, spiritual connections, and spiritual behaviors as the most important subcategories that should be considered during and after COVID-pandemic. What the study revealed was in agreement with findings reported by Ghaderi and colleagues (2018). They tried to provide a definition for the spiritual health. By interviewing 21 experts, they were able to find at least three dimensions for spiritual health (including religious, individualistic, and material world-oriented). Their participants distinguished between spiritual health and spirituality; they believed following the spiritual health factors affects the bio-psycho- and social aspects of health [30]. At the time of pandemic, spirituality went through positive and negative perspectives. For example, Büssing and colleagues investigated a specific topic about spirituality “spiritual dryness” during COVID-19 in Iran. They found the spiritual struggle/dryness between 27 and 35% among their participants. The best and positive predictors were usage of mood-enhancing medications, loneliness/social isolation, and praying and negative predictor was being restricted in daily life concerns [31]. At the same time, there are some studies that showed patients with COVID-19 whose spiritual health was enhanced could effectively adapt to their illness [32].

The present study revealed that social determinants of health during COVID-19 were similar to those ones before the pandemic, however, their effects were intensified. Accordingly, Abrams and Szefler (2020) emphasized that the effect social determinants of health have been underestimated during COVID-19. They expand their commentary by the relying on the results of the studies on how the poverty, physical environment (such as, smoke exposure, homelessness), and race or ethnicity might increase the chance of morbidity and mortality with COVID-19. They stated while COVID-19 has been considered as a great equalizer, its outcomes brought up inequalities in social health [33]. Similarly, Singu and colleagues (2020) in a review article took a step further and highlighted the effect of social determinants of health on the outbreak of COVID-19. In a five-dimension model, they showed five social determinants health factors (health and health care, Economy stability, Education, Neighborhood & Built Environment, and social & community context). They also used documents and studies to show how these five factors put people in a hierarchy and vulnerable to the COVID-19 [9]. Hiscott and colleagues (2020) expanded what Abrams & Szefler or Singu and colleagues wrote and added up many details on how social determinants of health changed during COVID-19 and how effective these determinants were [34]. They discussed how strict social distancing measures and home quarantine have resulted in the bankruptcy and closure of many businesses worldwide [29]. Consequently, some individuals have turned to drugs, tobacco, alcohol, gambling, and online gaming to cope with stress, which, in turn, significantly increases domestic violence and sexual abuse [28]. Lifestyle changes during the COVID-19 pandemic, such as increased solidarity, attention to and adherence to health guidelines, and reduction in social gatherings (e.g., weddings), have been observed in various communities throughout the pandemic.

Regarding the influential role of social factors on health after COVID-19 pandemic, according to experts’ opinions, the changes that occurred during the pandemic may persist even after it ends. Studies from other countries reached to similar perspective that danger in social health inequity would last to the post-COVID-19 unless proper policies and interventions to tackle vulnerability in living, education, employment, and poverty design and implement [35]. Lukkahatai and colleagues (2023) took a conserving position about the persistence symptoms of COVID-19 and wrote that “the persistent symptoms of long COVID-19 are less clear”. To be able to provide a proper explanation about the effects of post-COVID-19 on social determinants of health, they used WHO’s model. In this model, to reach appropriate health outcomes two groups of determinants including structural and intermediary are interacting. Details on these two groups are in fact those seven themes that we found in our first step to define the social determinants of health during the COVID-19. The WHO defines socioeconomic and political context and socioeconomic position as the structural determinants and material circumstances, behaviors and biological factors, and psychosocial factors as intermediary determinants. The inter and inter relationship among all these factors and determinants will provide time to resolution of symptoms, health care utilization, quality of life (these three variables as a collection considered to be the ‘health outcomes’) [36]. During the post-COVID-19 period, the number of television viewers and the percentage of activity on social networks are expected to increase significantly [37]. Economic recession, a decline in marriage rates, increased anxiety, and a lack of confidence in the future will reduce fertility rates and lead to consequences such as family disintegration and increased financial pressure [30]. Both during COVID-19 and afterward, significant changes will be observed in social systems and norms.

Conclusion

Given the wide range of social factors affecting health and their mutual influence on biological and spiritual aspects, we assume each community must identify these factors and plan for their control to overcome social health challenges during and after crisis such as COVID-19. However, this complexity should not stop planners from acting and implementing comprehensive programs, as the effects of pandemics can lead to lifestyle changes during and after, significantly impacting social structures.

Research limitations

This study faced limitations, such as the lack of transparency in the division boundaries of the dimensions of social factors affecting health and the creation of interferences within each size. The impact of the coronavirus disease on increasing or decreasing the valuation of influential social factors on health (for example, the increased importance of social justice and decreased social participation due to medical quarantine) and access to scattered and fragmented results in global and national studies were also challenges. However, the researchers tried to identify the most influential health factors, particularly social ones, that are important for the Iranian community.

Application of the Research

The researchers hope that presenting the socially influential factors on health in the post-COVID-19 era can assist health policymakers in making more practical decisions.

Recommendation

Identifying and formulating an operational plan to reduce the adverse effects of the above interactions is recommended by specifying the areas relevant to long-term, medium-term, and short-term practical programs affected by social factors during the COVID-19 pandemic. Additionally, it will be interesting to find out what social determinants on health were reinforced and what was minored after the COVID-19 pandemic.

Data availability

The datasets used and/or analyzed during the current study available from the first author on reasonable request.

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Acknowledgements

The authors express their utmost gratitude and appreciation to all the experts and clinical specialists who participated in the interviews and shared their experiences and opinions. The first author wishes to offer her special thanks to Dr. Masoomeh Salmani, respected associate professor in department of speech and language therapy, who cooperated with us in drafting and proofreading of this manuscript.

Funding

All costs of the present study have been paid by the first author.

Author information

Authors and Affiliations

  1. Doctoral student of educational management of Semnan University, Department of Midwifery, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran

    Farideh Izadi sabet

  2. Department of Education Management, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran

    Aliakbar Aminbeidokhti

  3. Department of Education Management, Faculty of Psychology and Educational Sciences, Semnan University, Central Administration of Semnan University, Campus 1, 35131-19111, Semnan, Iran

    Sakineh Jafari

Authors
  1. Farideh Izadi sabet
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  2. Aliakbar Aminbeidokhti
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  3. Sakineh Jafari
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Contributions

FIS, SJ, and AMB conceived and designed the study. FIS and SJ collected and checked the data. FIS and SJ analyzed the data. FIS and SJ drafted the manuscript. FIS, SJ, and AMB revised the manuscript, and FIS submitted the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Aliakbar Aminbeidokhti.

Ethics declarations

Compliance with Ethical Codes in Research

This study was conducted with the approval of the Ethics Committee of Semnan University of Medical Sciences (ethics code number = IR.SEMUMS.REC.1402.3584). After obtaining permission from Semnan University, researchers-initiated data collection. The study objectives were explained to all participants. Informed written consent was obtained from each participant for their participation in interviews, and audio recordings. Participants were also assured data confidentiality and assigned individual codes during quotations. Their participation was voluntary, and they could withdraw from the interviews at any time. After completing the study, the research results were communicated to the participants.

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Not applicable.

Competing interests

The authors declare no competing interests.

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sabet, F.I., Aminbeidokhti, A. & Jafari, S. Social determinants of health during and after coronavirus: a qualitative study. BMC Public Health 24, 283 (2024). https://doi.org/10.1186/s12889-024-17785-7

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Keywords

BMC Public Health

ISSN: 1471-2458

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