Help Seeking Behaviors During COVID 19 Pandemic in Iran: A Qualitative Study

Introduction

Each person with coronavirus disease 2019 (COVID-19) can infect an average of 8 people, although this rate increases by 70% in mutated forms of the disease such as delta. Also, in omicron variant, rate of infection transmission is 30 times that of delta strain(1). The COVID-19 symptoms are usually cough, fever, headache, and fatigue. This disease  is asymptomatic in 80% of cases (2). So far, coronavirus disease has led to over 400 million infected cases and almost 6 million deaths worldwide. Iran's share in this pandemic is 1.5% of infection rate and 2.3% of mortality rate (3).  The unique features of COVID-19, including high transmission, long incubation, and rapid spread, make it difficult to control the disease. Lack of definitive treatment, restriction of vaccine production and the related complications, and genetic mutation of the virus strengthen the virus transmission chain (4). The COVID-19 management obviously depends on different factors, such as accurate identification of transmission chains and different community responses or help-seeking behavior to deal with them. Help-seeking behavior is important tool to explore and understand patient's delays and take immediate action on a variety of health conditions(5). This process is characterized by problem focused, intentional action and interpersonal interaction (6). Accurate and in-depth identification of patient-seeking behavior, while explaining this process, determine the related factors, challenges, strengths and weaknesses, and depict participants' expectations for optimization, and improvement (7).

The literature review showed that during outbreaks, cultural variation, economic conditions, social beliefs, and psychological problems, such as fear of death and loneliness, anxiety, depression, and stigma due to critical condition, can affect help-seeking behavior and treatment process (8-10).

Obviously, identifying different behaviors and factors affecting them can help the health system provide more effective cares and services.

This study used the explanatory model based on Kleinman’s theory (11) to describe the help-seeking process during COVID-19 pandemic in terms of psychological, social, and behavioral dimensions. According to Kleinman's theory, there are three main sectors in clinical process including popular, professional and folk sectors which describe different dimensions such as beliefs, choices, decisions, roles, relationship, and behaviors in help seeking process related to clinical situation.  This study was performed aimed to accurately identify the help seeking behaviors from various aspects to determine the transmission chain and ways to control the disease.

Methods

Study design

This qualitative study was performed using a directional content analysis based on Graneheim and Lundman method (12) which is an applicable fast method to find adequate information with more individuals and less time.

Sample and setting

This study was performed from June to September 2020 on 15 individuals (women and men) living in Tehran, with mean age of 43.4 ± 10.25 years, who were confirmed as COVID-19 cases. The inclusion criteria were ability to communicate, and at least two weeks from the disease onset. Purposive sampling technique (13) was used to select the participants with different characteristics such as gender, age, marital status, educational level, and occupation, aimed to obtain maximum variation in the participants` experiences regarding help-seeking behavior (Table 1).

Procedures and data collection

Participants were selected in collaboration with the physicians of corona hospitals. The patients who met the inclusion criteria were selected. Data were collected using in-depth and semi-structured interviews. Fifteen interviews were determined based on data saturation. Each interview averagely lasted 45 to 60 minutes, and ended when no new concept could be extracted. Two well-trained qualitative research experts conducted all interviews via phone considering the COVID-19 pandemic and its social constraints such as social distancing and limited transportation. Before each telephone interview, the interviewer explained the study's objectives and asked the selected participant to introduce herself/himself. After obtaining the verbal consent from the interviewees to participate in the study, a suitable time was determined for each interview session.

Semi- structured interviews

The interview session began by calling each participant at the appointed time and asking warm up questions. The interviewer conducted all interviews. In case of any unpredictable problem during the

Table 1. Participants’ demographic characteristics in COVID-19 study

interview, it was postponed to another time.

In each phone session, a guide questionnaire was used to conduct the interview. The questionnaire was designed by the authors based on a comprehensive literature review regarding the subject and validated with expert group discussion. After the introduction, each interview began with general questions, such as “when did you notice your illness? Please explain.” The interview continued with other questions such as “And what did you do?” The help-seeking behavior concept was also debated. During each interview, the participants were encouraged to express openly about their experiences and opinions. Probing items such as where, when, how were mentioned to ensure proper understanding of considered concepts by the participants, and extract new concepts. According to Klein man's theory, various economic, social, cultural aspects, beliefs, decisions, etc. were also examined in depth and carefully in order to better understand the help seeking behavior. Each interview ended when no new issues were expressed.

Data analysis

All telephone interviews (in Persian) were recorded using a digital voice recorder. Each interview was transcribed immediately after the session without revealing the participants’ names or personal information. Data were analyzed using directional content analysis based on Graneheim and Lundman method (12). All the transcribed interviews were imported into the Open code qualitative software (version 4.2.) for data management and analysis.  The transcriptions were read word by word several times, and primary codes were identified and then similar codes were merged to form subcategories and the most similar codes existed in each category. Finally, the main categories were formed.

Trustworthiness

Various aspects of trustworthiness were observed based on Guba and Lincoln (14). Peer check, member check and expert check with enough time and prolonged engagement were used to maintain the credibility of data. External check by two qualitative research experts was performed to meet the criterion of dependability. Details of methodology, including data collection, data analysis, and coding, were explicitly recorded to promote transferability. The consistency was observed during the analysis process.

All the subjects verbally accepted to participate in the study. They were assured that their names, responses, and personal information would remain confidential. They were told that they can relinquish the interview at any time during the session. Permission to record the interview was obtained. The Ethical Committee of the University of Social Welfare and Rehabilitation Sciences approved the study protocol.

Results

The mean age of participants was 43.4 ± 10.25 years. The classification and summarization of the codes

Table 2. help seeking behaviors in COVID 19 epidemic based on Kleinman theory in residents of Tehran.

based on Kleinman’s theory (11) led to the emergence of 3 main categories and 13 subcategories in this study. The main categories included popular sector, Professional sector and folk sector (Table 2).

Popular sector:

This main category has four levels including individual, familial, social and community.

In individual level

Based on the participants' experiences, patients took two main steps, including telephone counseling and self-medication, to deal with the first suspicious symptoms of the Covid-19. Almost all the participants contacted phone numbers such as 1490 and 4030 announced by the Ministry of Health to receive advice or services related to COVID-19. However, they didn’t satisfy with prescribed recommendations in some cases. Also, most of the participants experienced self-medication such as using herbal teas, incense, regular analgesics or warm fluids with the onset of mild COVID-19 symptoms. In severe cases, going to the hospital and calling the emergency number 115 have been expressed.

“I was afraid that if I went to the hospital to get Covid disease, I would try to treat myself". (P13)

In family level

 Help-seeking behavior was limited to the expectations from main family members (people living under one roof) and other relatives and friends in dealing with COVID-19 patients. Due to the high transmission rate of the disease, the main concern of most participants was the risk of infecting main family members and they asked them to leave the house in some cases. But at the same time, most participants expected from other relatives to help and support them. It seems there is a conflict of expectation between main family members and other relatives.

 “We had no expectations from our main family members and wished them healthy, but we expected from other relatives to help us ". (P5)

Primary caregivers played a major role in the recovery and treatment process of the disease during COVID-19 epidemic. Most of the married participants, especially men, praised the role of their spouses in the recovery process. Preparing fresh food and fruit juices, making daily purchases, disinfecting, sustaining peace and maintaining vitality at home, and praying were examples of the spouses' activities.

” I would have died if my wife had not helped me. It both cheered me up and made me fresh food, and it didn't leave me alone even though she might get sick”. (P6)

In Social level

Help-seeking behaviors are described in two sub-categories, including donors, charities and non-governmental organizations, and other organizations, especially media. Some of the participants believed that during COVID-19 pandemic, charities provided services such as actively identifying the poor and providing financial assistance to them, disinfecting public places and passages, assisting in nursing care in hospitals, assisting in bathing and burials due to COVID-19. According to the participants’ experiences, media played a major role to make and maintain peace or, conversely, anxiety and chaos in times of crises.

“In the COVID-19 pandemic, radio or television have critical and special roles in presenting real news “. (P10)

 Furthermore, social media as one of the most accessible sources of information plays a major role in providing information and news. The only major challenge for these sources of information is that they may provide unreliable information as they are not monitored by competent authorities.

In community level

 Adherence to moral principles is one of the essential points that is more evident in times of crisis. “Unfortunately, in the Corona crisis, some people hoard basic necessities, masks, etc., and sell them at a high price. The phrase uttered by one of the participants was “Fishing in troubled waters”. (P8)

 Also, many of participants believed that financial and psychological support especially for vulnerable groups, is effective in improving critical situations.

 “We should not be incuriosity about each other. We need to know about our neighbor”. (P1)

Professional sector

According to the participants' experiences, professional sector especially health system was the main organization dealing with the COVID-19 pandemic. In fact, this system was the main reliable source of information, and also, played a key role in the diagnosis, treatment, and counseling of the disease. From the participants’ view, the medical staff is a strong and reliable pillar against COVID-19.

 In this level, help-seeking behavior has three subcategories including training, medical insurance and emergency services. Necessary training was provided at both general and specific levels. General training was provided for general population via media, and specific training was prepared for specialized medical staff. According to the participants' experiences, in all governmental hospitals, COVID-19 was covered by insurance, but the treatment cost was very high in private hospitals.

” We went to governmental hospital and it was almost free". (P15)

Some health system measures related to emergency services, based on participants' view, included equipping special ambulances in acute and emergency situations, performing primary care such as oxygen therapy, and admission to relevant hospitals.

Folk sector

Many of the participants believed that COVID-19 was God's punishment for people’s sins. Some of them believed that social injustice or oppression on each other was the cause of COVID-19. “God wanted to cleanse the earth of evil people…” (P8) “Corona is a plague that clears the earth from sinful people”. (P12)

Some of the participants attributed coronavirus disease to the Sino-US war for world domination. In addition, some of them believed that the disease is the result of a scientific error in Chinese laboratories.

Discussion

In this study, help-seeking behavior was investigated in patients with COVID-19 based on an explanatory model. Three main categories were extracted based on Kleinman theory (11) including popular, professional and folk sectors in help-seeking behavior. In popular sector, four levels of help seeking behaviors including individual, family, social and community were investigated.

Phone consultation and self-medication were the two main subcategories in individual level. Based on some studies during Covid-19 pandemic, different types of counseling such as expert counseling, telephone and video counseling have been used that has many advantages such as higher speed, lower cost, lack of transmission risk, etc (15). Self-medication, while reducing the costs of medication and health care, poor self-medication can lead to misdiagnosis, serious side effects, microbial resistance and etc. Therefore, there is an urgent need to control and manage appropriate SM practices by enforcing strong rules and engaging healthcare professionals and policymakers (16). In some studies, in family level, the role of family cares at the frontline is significant (17). In the present study, the spouse's role in controlling and coping with COVID-19 was significant and important. Also, the patients’ main concern was the illness of other family members. These results are consistent with the findings of several studies (18, 19). In social level, based on the participants’ experiences, mass and social media play a main role in providing the information related to COVID-19, although they act like a double-edged sword. Fake news and rumors can spread via social media. Invalid data and misinformation can cause anxiety, fear, and panic attacks among people (20). Social media is now a vital concern for the government and public health authorities worldwide (21). In professional sector, the role of health system during COVID 19 outbreak were extracted with three main duties including training, medical insurance and emergency services. Based on Debra et al.’s study, the behavioral health system has five key missions: prevention, protection, mitigation, response, and recovery in the COVID-19 pandemic (22). It appears that training is also one of the main functions of the health system, which fortunately was considered in Iran.

In the present study, in folk sector, the participants' beliefs based on their experiences related to COVID-19 were assessed. The majority of participants believed that the two main causes of Covid-19 are Gods’ punishment for peoples` sin and the scientific error. Based on some other studies, COVID-19 is originated from a seafood market in Wuhan (23), but participants said this pandemic is a god punishment.

Managing limited human resources in the health system is obviously one of the most important strategies to develop and maintain healthcare services during COVID-19 pandemic (24). One of the most significant strengths in this study is the use of a qualitative approach and deep understanding the help-seeking behavior based on the explanatory model of Kleinman’s theory (11), making it possible to better identify help-seeking behavior from various aspects and design appropriate programs to develop the help-seeking process.

The limitations of the present study were lack of generalizability of the results and failure to conduct face-to-face interviews due to the potential risk of COVID-19 transmission.

Implications for practice

It is clear that exploring help-seeking behaviors at different levels can help the national health system to better control COVID-19 pandemic and provide preventive services.

Acknowledgments

This study was approved and financially supported by the University of Social Welfare and Rehabilitation Sciences (Approval No 2477). Also, it has been approved by University Ethical Committee (Code: IR.USWR.REC.1399.060). The authors expressed their sincere appreciation to all individuals who participated in this study.

Conflicts of interest

The authors declare that they have no conflict of interest.