ORIGINAL RESEARCH
published: 29 September 2021
doi: 10.3389/fpsyg.2021.671124
Edited by:
Jason H. Huang,
Baylor Scott and White Health,
United States
Reviewed by:
Han Zheng,
Nanyang Technological
University, Singapore
Wenwang Rao,
University of Macau, China
*Correspondence:
Elham Akhlaghi
elham.akhlaghi72@yahoo.com
Samaneh Torkian
Torkiansamane72@gmail.com
† ORCID:
Elham Akhlaghi
orcid.org/0000-0003-3552-1685
Samaneh Torkian
orcid.org/0000-0002-7913-2801
Vahid Khosravi
orcid.org/0000-0002-7994-800X
Reza Etesami
orcid.org/0000-0003-4141-8852
Erika Sivarajan Froelicher
orcid.org/0000-0003-1852-8922
Hamid Sharif Nia
orcid.org/0000-0002-5570-3710
Saeed Pahlevan Sharif
orcid.org/0000-0001-8082-4541
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 22 March 2021
Accepted: 12 July 2021
Published: 29 September 2021
Citation:
Sharif Nia H, Akhlaghi E, Torkian S,
Khosravi V, Etesami R, Froelicher ES
and Pahlevan Sharif S (2021)
Predictors of Persistence of Anxiety,
Hyperarousal Stress, and Resilience
During the COVID-19 Epidemic: A
National Study in Iran.
Front. Psychol. 12:671124.
doi: 10.3389/fpsyg.2021.671124
Frontiers in Psychology | www.frontiersin.org
Predictors of Persistence of Anxiety,
Hyperarousal Stress, and Resilience
During the COVID-19 Epidemic: A
National Study in Iran
Hamid Sharif Nia 1† , Elham Akhlaghi 2*† , Samaneh Torkian 3*† , Vahid Khosravi 4† ,
Reza Etesami 5† , Erika Sivarajan Froelicher 6,7† and Saeed Pahlevan Sharif 8†
1
Department of Nursing, Mazandaran University of Medical Science, Sari, Iran, 2 Department of Medical Surgical Nursing,
School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran, 3 Department of Epidemiology, School of
Public Health, Iran University of Medical Sciences, Tehran, Iran, 4 Health Education and Promotion, School of Public Health,
Shahid Sadoughi University of Medical Sciences, Yazd, Iran, 5 Department of Statistics, Shahid Bahonar University, Kerman,
Iran, 6 Department of Physiological Nursing, Schools of Nursing, University of California, San Francisco, San Francisco, CA,
United States, 7 Department of Epidemiology & Biostatistics, Schools of Medicine, University of California, San Francisco,
San Francisco, CA, United States, 8 Taylor’s Business School, Taylor’s University, Subang Jaya, Malaysia
Background: The coronavirus pandemic can cause unprecedented global anxiety,
and, in contrast, resilience can help the mental health of people in stressful situations.
This study aimed to assess anxiety, hyperarousal stress, the resilience of the
Iranian population, and their related factors during the coronavirus disease 2019
(COVID-19) epidemic.
Methods: A cross-sectional study was conducted in 31 provinces in Iran between
March 18 and 25, 2020. A four-part questionnaire, including the demographic
information, the State-Trait Anxiety Inventory (STAI-y1—a 20-item standard questionnaire
for obvious anxiety), the Connor–Davidson Resilience Scale (CD-RISC—a 25 item
standard questionnaire), and the stress hyperarousal subscale from the Impact of Event
Scale-Revised (IES-R), was used to collect data. The ordinal multivariable generalized
estimating equation (GEE) model was used to identify correlates of the psychological
factors mentioned above. The Fisher exact test was used to investigate the relationship
between anxiety, stress, resilience, and the COVID-19 outbreak. All analyses were
conducted with SPSS 26 and GIS 10.71.
Results: The findings show that most people had moderate-to-severe anxiety
(80.17%) and a high level of resilience (96.4%) during the COVID-19 epidemic. The
majority of participants had a moderate level of stress (58.9%). The lowest and
highest prevalences of psychiatric disorders were in Sistan and Baluchestan (3.14
cases per 100,000 people) and Semnan (75.9 cases per 100,000 people) provinces,
respectively. Men and unmarried people were the only variables significantly associated
with anxiety and resilience. Age, gender, and education were significantly associated with
hyperarousal stress.
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Sharif Nia et al.
Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
Conclusion: The high and moderate levels of anxiety and stress in Iranians can have
negative effects on the well-being and performance of the people and can lead to
serious problems. Also, high resilience during negative life events (such as the COVID-19
pandemic) is associated with the well-being in the lives of people. The results of this study
can be used in interventions and other psychological studies.
Keywords: anxiety, COVID-19, mental health, hyperarousal stress, resilience
INTRODUCTION
ones and is expensive due to the overuse of health services (Fink
et al., 2010).
Anxiety, as a form of psychological stress, can also cause
physiological changes and weakens the immune system (Liu et al.,
2020). The immune system can protect against pathogens and
can have positive effects by reducing stress and anxiety of patients
(Reed and Raison, 2016; Li G. et al., 2020).
One study found that symptoms of anxiety in the COVID19 epidemic were present among people under the age of 35
and those who spent a lot of time focusing on the epidemic and
did not show a difference in anxiety between men and women
(Huang and Zhao, 2020), while women were more anxious than
men in other studies during this pandemic (Guo et al., 2016; Gao
et al., 2020).
The field of psychology recognized the interaction between
the individual and the environment (Masten and Reed, 2002)
in the late nineteenth and early twentieth centuries. Connor
and Davidson regard resilience as the ability of an individual to
maintain a psychological balance in perilous situations (Connor
and Davidson, 2003).
Considerable research on the role of resilience under various
situations has shown that resilience can help people in the
face of stressful life adversity (Izadinia et al., 2010). It can also
modulate levels of stress and disability in stressful situations and
enhance problem-solving skills (Pinquart, 2008). Resilient people
use coping skills to deal with stress (Campbell-Sills et al., 2006).
Resilience is about improving social activities and overcoming
problems despite exposure to severe stress, anxiety, and difficult
life experiences. Resilience is the ability to grow, mature, and
increase the capacity of an individual against adverse conditions
(Amiry, 2019). Resilience is an adaptation that manifests itself
during debilitating problems and stresses. This definition of
resilience states that there is a complex interaction between
a dangerous situation and the protective factors (Cénat and
Derivois, 2014).
It is also important to prevent anxiety among people, to teach
them health principles, and to maintain calmness (Farnoosh
et al., 2020). Findings from this study can guide the designing
and implementation of policies for mental health interventions to
effectively address this challenge. Based on the limited evidence of
the stress during earlier epidemics, this study hypothesized that,
given the severity of the COVID-19 pandemic, similar adverse
psychological responses may manifest (Maunder et al., 2003).
The main purpose of this study is to measure the severity of
anxiety, stress, and resilience in Iranians in order to determine
the current mental health needs and to design interventions for
the Iranian population.
The novel coronavirus disease 2019 (COVID-19) first appeared
in Wuhan, Hubei Province, China, in late 2019, and it rapidly
spread throughout China and to nearly every country in the
world (Bogoch et al., 2020). A pandemic was declared by World
Health Organization (WHO) in March 2020 (Zhu et al., 2020).
According to the WHO statistics, more than 184,820,132 people
have been infected, and more than 4,002,209 deaths have been
recorded worldwide as of July 8, 2021. Iran has the 13th highest
number of coronavirus infection cases in the world. Between
February 19 and 23, 2020, Iran reported 43 confirmed cases and
8 deaths in Qom. Since July 2021, the coronavirus toll in Iran
reached 3,327,526 infections and 85,397 deaths (World Health
Organization, 2021). The coronavirus outbreak reached its peak
in 2 months in China and in <1 month in Iran (World Health
Organization, 2021).
Because of the high transmissibility of the COVID-19, it can
spread from person to person even if the person is asymptomatic
(Li Q. et al., 2020; Pan et al., 2020). The very high number
of confirmed cases and high fatality rates have resulted in
psychological problems such as stress, anxiety, and depression
among the medical staff as well as in the community (Kang et al.,
2020; Qiu et al., 2020; Xiang et al., 2020). The general panic
caused by the coronavirus outbreak has increased the symptoms
of anxiety (Huang and Zhao, 2020). These symptoms are related
to the natural protective response of the body against the stress of
the pandemic (Maunder et al., 2003). The stress response system
has both positive and negative aspects (Nesse et al., 2016); while
the stress response system causes symptoms, it also has long-term
benefits by increasing adaptability; therefore, responding to stress
is to some extent a necessary and beneficial mechanism (Charney,
2004).
Another response to stress is the activation of the sympathetic
system coupled with symptoms such as increased arousal, fever,
sweating, and respiratory rate (Nesse et al., 2016). To that
end, research has shown that anxiety can also cause dyspnea
(Hinz et al., 2012; Holas et al., 2017). For some people, it can
be confusing to identify the difference between symptoms of
stress and coronavirus because coronavirus shares some of the
symptoms with panic, such as fever, sweating, and dyspnea
(Chen et al., 2020; Huang et al., 2020). Thus, excessive and
constant anxiety is a common and debilitating problem that
causes considerable suffering for the individual and their loved
Abbreviations: STAI, State-Trait Anxiety Inventory; CD-RISC, Connor–Davidson
Resilience Scale; IES-R, Impact of Event Scale-Revised; GEE, Generalized
estimating equations; CIs, Confidence intervals; OR, Odds ratio.
Frontiers in Psychology | www.frontiersin.org
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Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
METHODS
(Panaghi and Mogadam, 2006; Jowkar et al., 2010; Keyhani et al.,
2015; Mahram, 2018). In this study, Cronbach’s alpha for the
anxiety questionnaire, the stress questionnaire, and the resilience
questionnaire were 0.85, 0.73, and 0.93, respectively.
Also, the data of incidence of COVID-19 were obtained
from the cases announced from the latest news of the
provinces between March 6 and 20, 2020 to investigate the
relationship between the COVID-19 outbreak and anxiety, stress,
and resilience.
A cross-sectional study was used to evaluate the psychological
responses in the general population in Iran during the COVID19 pandemic from March 18 to 25, 2020. Data were collected
with a web-based questionnaire in 31 provinces in Iran using a
snowball-sampling technique. The aim was to measure anxiety,
hyperarousal stress, and resilience in this critical situation. A total
of 70,180 persons completed the questionnaire. This study was
limited to individuals who had access to the web (to complete the
questionnaire) and were literate. Participation in this study was
voluntary and confidential.
A four-part questionnaire, including the demographic
information, the State-Trait Anxiety Inventory (STAI-y1—
a 20-item standard questionnaire for obvious anxiety), the
Connor–Davidson Resilience Scale (CD-RISC—a 25-item
standard questionnaire), and the stress hyperarousal subscale
from the Impact of Event Scale-Revised (IES-R), was used to
collect the data.
Demographic variables included gender (male and female), age
(<30, 31–40, 41–50, and >50), marital status (married, single,
divorced, and widowed), chronic pre-existing conditions (yes
or no), education (diploma or less, associate degree, bachelor,
masters, and doctorate), job (health workers and others), and
economic status (good, moderate, and poor).
The anxiety measure STAI-y1 has 20 items, and all items
were rated on a 5-point scale (from “Almost Never = 1” to
“Almost Always=4”). A score of four indicates greater anxiety,
but for questions 1, 2, 5, 8, 10, 11, 15, 16, and 19, a high
score indicates a lack of anxiety, and grading weights for these
questions are reversed (Julian, 2011). This questionnaire was used
to evaluate the anxiety symptoms during the past week. The
STAI-y1 questionnaire was scored from 20 to a maximum of 80
points. STAI-y1 scores are commonly classified as “no or low
anxiety” (20–37), “moderate anxiety” (38–44), and “high anxiety”
(45–80) (Козьминых, 2019).
The resilience measure CD-RISC consists of 25 items that are
evaluated on a 5-point Likert scale ranging from 0 to 4: not true
at all (0), rarely true (1), sometimes true (2), often true (3), and
true nearly all of the time (4). These ratings result in a number
between 0 and 100, and higher scores indicate a higher resilience
(Connor and Davidson, 2003). The cut-point for the resilience
questionnaire was based on the Likert score, and the average
score of the questionnaire was used (Garland, 1991; Narli, 2010).
Accordingly, participants with mean scores of ≤1.33, 1.34–2.66,
and 2.67–4 were regarded as having low resilience, moderate
resilience, and high resilience, respectively.
The stress hyperarousal subscale consisted of six questions
from the IES-R questionnaire. IES-R included the three subscales:
intrusion (eight items), avoidance (eight items), and hyperarousal
(six items); we used only the hyperarousal subscale (Beck et al.,
2008). The 5-point Likert scale response options were used (0–
4): not true at all (0), rarely true (1), sometimes true (2), often
true (3), and true nearly all of the time (4). The score ranges are
from 0 to 24, and higher scores indicate more stress (Christianson
and Marren, 2012). The high reliability and the validity of the
three questionnaires have been established in earlier studies
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Ethical Approval and Consent to
Participate
Ethical approval for this study was obtained from the
Mazandaran University of Medical Sciences. The Ethical Code
IR.MAZUMS.REC.1399.7293 was assigned to this study. On the
first page of the questionnaire, the objectives of the study, the
email ID for questions, the ethics of the study, and information
about the optional participation in the study and their anonymity
given to the participants were explained.
Statistical Procedures
In this study, the dependent variables had three categories;
therefore, we used the ordinal multivariable generalized
estimating equation (GEE) models to identify correlates of the
psychological factors mentioned above. Odds ratios (ORs) with
95% confidence intervals (CI) were reported. The geographic
information system (GIS) was used to draw hotspots of anxiety,
stress, and resilience. This method used the median, and
the hotspots for anxiety, stress hyperarousal, and resilience
in Iran were plotted. The cutoffs were the same as those
mentioned above, but the median was used instead of the
mean. The incidence risk of COVID-19 (confirmed COVID-19
cases/population at risk) between March 6 and 19, 2020 was
′
shown in a bar chart. The Fisher s exact test was used to
investigate the relationship between the COVID-19 outbreak
with anxiety, stress, and resilience. A P < 0.05 was considered
statistically significant. We conducted all analyses using SPSS 26
and GIS 10.71.
RESULTS
In this survey, most of the participants were male (64.3%), were
married (75.8%), had a bachelor degree (37.6%), had a mediumincome level (70.4%), and had no chronic pre-existing conditions
(80.9%). The mean age (±SD) of the participants was 41.21
(±11.71) years.
The prevalence of anxiety, stress, and resilience in subgroups
by demographic variables is shown in Table 1. The anxiety, stress
hyperarousal, and resilience in Iranians during the COVID-19
epidemic were means (SD) of 47.64 (±11.51), 10.28 (±3.91), and
64.74 (±16.44), respectively. In this study, 59.4% of the people
reported high anxiety, 20.8% reported moderate anxiety, and
19.8% reported low anxiety. Most of the Iranians had moderateto-severe anxiety (80.17%) during the COVID-19 epidemic.
A high level of stress hyperarousal was reported by 6.6%; a
moderate level was reported by the majority of people (59.4%),
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TABLE 1 | Characteristics of participants according to the demographic and the psychological variables during the COVID-19 pandemic (n = 70,180).
Variables
n (%)
Resilience
Low
Anxiety
Moderate
High
Low
Moderate
Stress
High
Low
Moderate
High
Gender
Male
25,037 (35.7)
902 (3.6)
9,556 (38.2)
14,579 (58.2)
12,063 (48.2)
686 (2.7)
12,288 (49.1)
8,580 (34.3)
14,738 (58.9)
1,719 (6.9)
Female
45,143 (64.3)
1,916 (4.2)
23,491 (52.0)
19,736 (43.7)
1,857 (4.1)
13,877 (30.7)
29,409 (65.1)
15,279 (33.8)
26,968 (59.7)
2,899 (6.4)
70,180
2,818 (4.0)
33,047 (47.1)
34,318 (48.9)
13,920 (19.8)
14,697 (20.8)
41,697 (59.4)
23,856 (34.0)
417.6 (59.4)
4,618 (6.6)
Total
Age (years)
(8–30)
11,568 (16.9)
411 (3.6)
5,467 (47.3)
5,690 (49.2)
2,165 (18.7)
2,648 (22.9)
6,755 (58.4)
3,977 (34.4)
6,826 (59.0)
765 (6.6)
(31–40)
24,513 (35.7)
995 (4.1)
11,609 (47.4)
11,909 (48.6)
4,669 (19.0)
5,324 (21.7)
14,520 (59.2)
8,175 (33.3)
14,666 (59.8)
1,672 (6.8)
(41–50)
17,728 (25.8)
723 (4.1)
8,370 (47.2)
8,635 (48.7)
3,628 (20.5)
3,536 (19.9)
10,564 (59.6)
6,074 (34.3)
10,539 (59.4)
1,115 (6.3)
(51–99)
14,786 (21.6)
614 (4.2)
6,857 (46.4)
7,315 (49.5)
3,190 (21.6)
2,687 (18.2)
8,909 (60.3)
5,114 (34.6)
8,723 (59.0)
949 (6.4)
14,097 (20.1)
486 (3.4)
6,163 (43.7)
7,448 (52.8)
2,845 (20.2)
4,487 (31.8)
6,765 (48.0)
4,691 (33.3)
8,419 (59.7)
987 (7.0)
2,901 (4.1)
135 (4.7)
1,468 (50.6)
1,298 (44.7)
257 (8.9)
814 (28.1)
1,830 (63.1)
972 (33.5)
1,735 (59.8)
194 (6.7)
53,182 (75.8)
2,197 (4.1)
25,416 (47.8)
25,569 (48.1)
10,818 (20.3)
9,262 (17.4)
33,102 (62.2)
18,193 (34.2)
31,552 (59.3)
3,437 (6.5)
Marital status
Single
Divorce/Widowed
Married
Chronic pre-existing conditions
4
No
56,778 (80.9)
2,286 (4.0)
26,721 (47.1)
27,771 (48.9)
11,142 (19.6)
12,019 (21.2)
33,617 (59.2)
19,240 (33.9)
33,809 (59.5)
3,729 (6.6)
Yes
13,402 (19.1)
532 (4.0)
6,326 (47.2)
6,544 (48.8)
2,778 (20.7)
2,544 (19.0)
8,080 (60.3)
4,616 (34.4)
7,897 (58.9)
889 (6.6)
1,082 (5.8)
Education
18,526 (26.4)
772 (4.2)
8,855 (47.8)
8,899 (48.0)
3,544 (19.1)
3,829 (20.7)
11,153 (60.2)
6,483 (35.0)
10,961 (59.2)
7,170 (10.2)
311 (4.3)
3,387 (47.2)
3,472 (48.4)
1,487 (20.7)
1,379 (19.2)
4,304 (60.0)
2,355 (32.8)
4,375 (61.01)
440 (6.1)
Bachelor
26,373 (37.6)
1,029 (3.9)
12,459 (47.2)
12,885 (48.9)
4,868 (18.5)
5,693 (21.6)
15,812 (60.0)
8,969 (34.0)
15,612 (59.4)
1,792 (6.8)
Masters Doctorate
18,111 (25.8)
706 (3.9)
8,346 (46.1)
9,059 (50.0)
4,021 (22.2)
3,662 (20.2)
10,428 (57.6)
6,049 (33.4)
10,758 (59.4)
1,304 (7.2)
63,460 (60.4)
2,558 (4.0)
2,558 (4.0)
31,154 (49.1)
12,823 (4.0)
12,959 (20.4)
37,678 (59.4)
21,636 (34.1)
37,618 (59.3)
4,206 (6.6)
6,720 (9.6)
260 (3.9)
260 (3.9)
3,161 (47.0)
1,097 (16.3)
1,604 (23.9)
4,019 (59.8)
2,220 (33.0)
4,088 (60.8)
412 (6.1)
Job
Other
Health workers
Economic situation
September 2021 | Volume 12 | Article 671124
Good
11,449 (16.3)
463 (4.0)
5,585 (48.8)
5,401 (47.2)
1,841 (16.1)
2,555 (22.3)
7,053 (61.6)
3,830 (33.5)
6,890 (60.2)
729 (6.4)
Moderate
49,382 (70.4)
1,987 (4.0)
23,186 (47.0)
24,209 (49.0)
9,758 (19.8)
10,266 (20.8)
29,358 (59.5)
16,848 (34.1)
29,237 (59.2)
3,297 (6.7)
Poor
9,348 (13.3)
368 (3.9)
4,275 (45.7)
4,705 (50.3)
2,321 (24.8)
1,742 (18.6)
5,285 (56.5)
3,178 (34.0)
5,578 (59.7)
592 (6.3)
Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
Diploma and less
Associate degree
Sharif Nia et al.
Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
FIGURE 1 | The incidence risk of COVID-19 in the provinces of Iran from March 6 to 28, 2020.
Other sociodemographic variables including age, underlying
chronic disease, education, job, and economic situation were
not associated with the CD-RISC and STAI levels. Age groups
≤30, being single, diploma, and lower education level were
significantly associated with hyperarousal stress. Being single
(OR = 1.05, 95% CI: 1.01, 1.09) and age groups (≤30
years) (OR = 1.05, 95% CI: 1.00, 1.09) were significantly
associated with a higher IES-R subscale level and those who
had a diploma or education level (OR = 1.05, 95% CI: 1.00,
1.09) were significantly associated with a lower IES-R subscale
level. Other sociodemographic variables including gender,
widowed/divorced, age (except age groups ≤30), underlying
chronic disease, education (except diploma and less education),
job, and economic situation were not associated with the IES-R
subscale levels.
The median resilience score was significantly associated (p =
0.044) with an outbreak, but the median anxiety (p = 1.000) and
stress (p = 0.073) scores had no significant relationship with the
COVID-19 outbreak.
and 34% reported a low level of stress. Most of the people
reported moderate (47.1%) and high (48.9%) levels of resilience.
The incidence of COVID-19 in the provinces is shown in
Figure 1. The lowest and highest incidence risks of COVID19 were in Sistan and Baluchestan (3.14 cases per 100,000
people) and in Semnan (75.9 per cases 100,000 people)
provinces, respectively.
The median distribution of the anxiety score is shown in
Figure 2. As shown in Figure 2, the people in almost all parts of
Iran were highly anxious.
Figure 3 shows that many parts of Iran have moderate levels
of stress.
Figure 4 also shows the high and moderate resistances of all
parts of Iran.
The distribution of the incidence cases of COVID-19 in Iran
between March 6 and 28, 2020 is shown in Figure 5.
The association between the demographic variables and the
psychological impact of the COVID-19 outbreak is shown in
Table 2. The following demographic variables, gender (female),
age (>50 years), marital status (being married), having a chronic
pre-existing condition, education (masters degree), employment
(other jobs), and economic status (being poor), were reference
groups for the GEE models.
Gender and marital status were the only variables significantly
associated with anxiety and resilience. Being male were
significantly associated with a higher resilience level (OR =
1.76, 95% CI: 1.70, 1.82) and a lower anxiety level (OR
= 0.28, 95% CI: 0.25, 0.26). Marital status was significantly
associated with the CD-RISC and STAI levels. Being single
(OR = 1.25, 95% CI: 1.20, 1.30) and being widowed/divorced
were significantly associated (OR = 1.02, 95% CI: 1.00,
1.10) with higher resilience. Also, being single (OR =
0.57, 95% CI: 0.55, 0.59) and divorced/widowed (OR =
0.57, 95% CI: 0.55, 0.59) were significantly associated with
lower anxiety.
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DISCUSSION
The salient findings of this study include the following. Most
of the Iranians reported moderate-to-severe levels of anxiety,
moderate stress, and resilience during the COVID-19 pandemic.
These findings confirm those reported during the initial phase
of the COVID-19 outbreak in China, where about one-third of
the general population in China reported moderate-to-severe
anxiety (Wang et al., 2020). In Rome, 89.4% of students reported
an increase in stress (66% moderate and 23.4% high stress),
which remained consistent with our results (Quintiliani et al.,
2021). The prevalence of anxiety in a systematic review and
meta-analysis in 2016 in Iranians showed mild (31%), moderate
(37%), intense (19%), and highly intense (2%) levels of anxiety
5
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Sharif Nia et al.
Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
FIGURE 4 | Resilience in the provinces of Iran.
FIGURE 2 | Anxiety in the provinces of Iran.
FIGURE 3 | Stress in the provinces of Iran.
FIGURE 5 | Outbreak of COVID-19 in the provinces of Iran.
(Valizadeh et al., 2016). These findings suggest that an increase
in the prevalence of high anxiety during the COVID-19 epidemic
was reported.
Consistent with this study, Limcaoco et al. in their study
reported higher levels of anxiety in women during the COVID-19
epidemic (Limcaoco et al., 2020). Consistent with our findings,
Wang et al. showed in their study that gender and age were
associated with anxiety and that anxiety rates were higher in
women and younger people (<40 years). However, in our study,
<40 years of age was not associated with anxiety (Wang et al.,
2021). A meta-analysis study conducted until May 2020 showed
that the prevalence of stress in five studies with a total sample size
of 9,074 was 29.6% and the prevalence of anxiety in 17 studies
Frontiers in Psychology | www.frontiersin.org
with a sample size of 63,439 was 31.9%. The prevalence of stress
in this meta-analysis was higher than that of the severe stress in
the present study but the prevalence of anxiety was lower (Salari
et al., 2020).
High levels of stress and anxiety were not associated with
the COVID-19 epidemic in this study. We guess that stress
and anxiety are associated with the two important consequences
of the COVID-19 pandemic: availability of medical equipment
and economic status (Abdoli, 2020; Taherinia and Hassanvand,
2020). Iran is suffering from the political and economic sanctions
that have directly and indirectly restricted the activities of
its banking systems. This, in turn, has led to restrictions
on trade, the manufacturing sector, insurance, and ventures
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Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
TABLE 2 | The ordinal multivariable generalized estimating equation models to determine the correlates of the psychological impact of the COVID-19 in Iran (n = 70,180).
Variables
Resilience
Anxiety
Stress hyperarousal
OR (95% CI)
p-value
OR (95% CI)
p-value
OR (95% CI)
p-value
1.76 (1.70, 1.82)
<0.001
0.28 (0.25, 0.26)
<0.001
0.99 (0.96, 1.03)
0.960
1
1
1
1
1
1
(8–30)
0.98 (0.93, 1.03)
0.587
1.03 (0.97, 1.08)
0.243
0.99 (0.94, 1.05)
0.941
(31–40)
0.98 (0.94, 1.02)
0.436
0.96 (0.92, 1.01)
0.130
1.05 (1.00, 1.09)
0.022
(41–50)
0.98 (0.94, 1.03)
0.559
0.95 (0.91, 0.99)
0.047
1.00 (0.96, 1.04)
0.838
(51–99)
1
1
1
1
1
1
Single
1.25 (1.20, 1.30)
<0.001
0.57 (0.55, 0.59)
<0.001
1.05 (1.01, 1.09)
0.014
Divorced/Widowed
1.02 (1.00, 1.10)
<0.001
0.85 (0.79, 0.92)
<0.001
1.05 (0.97, 1.13)
0.217
1
1
1
1
1
1
No
1.00 (0.96, 1.04)
0.721
0.97 (0.93, 1.01)
0.269
1.01 (0.97, 1.05)
0.591
Yes
1
1
1
1
1
1
Gender
Male
Female
Age (years)
Marital status
Married
Chronic pre-existing conditions
Education
Diploma and less
0.96 (0.92, 1.00)
0.105
1.03 (0.98, 1.08)
0.150
0.91 (0.87, 0.95)
<0.001
Associate degree
0.96 (0.91, 1.02)
0.223
1.02 (0.97, 1.08)
0.353
0.99 (0.94, 1.05)
0.833
Bachelor
1.00 (0.91, 1.01)
0.847
1.03 (0.99, 1.08)
0.067
0.97 (0.93, 1.00)
0.125
1
1
1
1
1
1
0.96 (0.92, 1.01)
0.214
0.96 (0.91, 1.01)
0.159
1.00 (0.95, 1.05)
0.828
1
1
1
1
1
1
Good
0.98 (0.93, 1.05)
0.695
1.05 (0.99, 1.12)
0.060
1.00 (0.94, 1.06)
0.964
Moderate
1.01 (0.96, 1.06)
0.636
1.02 (0.97, 1.07)
0.335
0.98 (0.94, 1.03)
0.508
1
1
1
1
1
1
Masters/doctorate
Job
Health workers
Other
Economic situation
Poor
The bold values are indicate statistical significance.
(Abdoli, 2020). These conditions have hampered the provision
of basic medical equipment for the prevention, diagnosis,
and treatment of COVID-19. Concerns about the provision
of equipment needed for the prevention and treatment can
be one of the most important causes of fear and anxiety
in the community during the COVID-19 pandemic. The
COVID-19 pandemic plunged the world economy into a
recession (Hashemi-Shahri et al., 2020). This recession has
doubled the problems of the economy in Iran, and people are
worried about unemployment, inflation, and business closures
in Iran.
In this study, women presented with more symptoms of
anxiety than men, and this may be related to a greater exposure of
a women to stressful factors, such as a low socioeconomic status,
fewer resources, lack of energy, role overload, psychological
problems, and low self-esteem (Watkins et al., 2013; Carvalho
et al., 2016). The lower prevalence of these symptoms among men
may be attributed to what some authors have identified as men
compensated differently compared with women such as the use of
anger, aggressiveness, antisocial behavior, excessive consumption
of alcohol, smoking, and hostility (Watkins et al., 2013; Carvalho
Frontiers in Psychology | www.frontiersin.org
et al., 2016). Contrary to our findings, Broche-Pérez et al. in Cuba
showed that anxiety did not differ between genders (BrochePérez et al., 2021).
The WHO considers the COVID-19 pandemic to be a stressful
and anxious time for people (World Health Organization, 2021).
One of the reasons for stress and anxiety during the COVID-19
pandemic is the extensive news coverage of coronavirus causing
stress and anxiety. “Headline stress disorder” was first coined
by Dr. Steven Stosny who referred to mental disorders such as
stress and anxiety being caused by excessive attention to news
coverage. Also, the use of mobile phones provides wide news
coverage (Dong and Zheng, 2020). Until 2018, Iran had an
estimated Internet penetration rate of between 64 and 69% out of
a population of about 82 million, about 56,700,000, that increased
recently (Wikipedia, 2020). This study is limited to internet users,
which include about 68% of the population of Iran.
Connor and Davidson (2003) describe resilience as an ability
to cope with stress. Consistent with the present study, the
average psychological resilience score of the hospital staff after
the outbreak of the respiratory syndrome in South Korea showed
good resilience (Son et al., 2019). In another study, most of
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Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
and Telegram in order to be inclusive to the majority of the
news channels of the provinces of Iran. Another limitation of
this study was that the COVID-19 status of the participants was
not obtained. This omission is important as psychological stress
is likely to be much higher in those who were infected with
COVID-19 than those who were not infected.
the employees in Sierra Leone (in West Africa) had a resilience
score of 71–80 during the Ebola epidemic (Colorado, 2017),
indicating a high resilience; our results are similar. Similarly,
Bonnano (2004) defined resilience as the ability of an individual
to maintain a stable psychological equilibrium; this is the
counterpart to psychological vulnerability. According to these
definitions, resilience differs from recovery, accounting not for
the ability of an individual to “bounce back” after a negative
experience but for the ability of an individual maintain a steady
psychological state despite the changing circumstances (Seery,
2011).
Despite the long-term sanctions on Iran, the people have
faced and struggled with many problems (Abdoli, 2020).
With their minimum facilities and maximum capabilities,
they have used the opportunities for progress (Agheli and
Emamgholipour, 2020). This long-term compatibility is
probably one of the reasons for the high resilience of the
Iranian people.
The presence or absence of resilience greatly affects the
response of an individual to adverse life events. Individuals
with low resilience are more likely to experience psychological
distress following an adverse life event than individuals who
report high resilience (Faircloth, 2017). Differences in resilience
accounted for a variation in emotional responses following
adverse experiences. High accounts of resilience resulted in
weaker associations between stressful events and the emotional
state of an individual (Ong et al., 2006). The relationship between
a high level of resilience and men in the present study may be
because women use coping strategies more frequently, while men
focus on the problem itself, in which an individual opts to solve
difficulties and attitudes in order to be able to deal with the
habitual pressure, decreasing or even eliminating situations that
generate stress (Bazrafshan et al., 2014; Carvalho et al., 2016).
The WHO has six recommendations for the mental and
psychological well-being of people in a community, working
together as one community, and supporting the medical staff.
Also, instead of negative thoughts and excessive attention to
news, the experiences of people who have recovered from the
disease have to be followed up (World Health Organization,
2021).
The comprehensive support of the people from the
government, for example, easy access to preventive equipment,
rapid and free vaccination of the people, support of harmful
businesses in the COVID-19 pandemic, and redoubled efforts
to control the epidemic in Iran, can reduce the psychological
pressure of the people in this pandemic.
Limitations of this study include the use of a snowballsampling method. Given the emergence of this health crisis,
this sampling method was considered to be most appropriate.
Random sampling was not an option due to the lack of a sampling
frame. However, the large sample size of this study that covered
about one-tenth of a percent of the Iran population was a strong
representation of Iranian society. The web-based data collection
could however be a limitation, as not everyone in Iran has
access to the web. This problem was minimized because a link
to the questionnaire was published on Instagram, WhatsApp,
Frontiers in Psychology | www.frontiersin.org
CONCLUSIONS
The findings of this study showed a high-to-moderate level
of anxiety and resilience and a low-to-moderate stress in this
Iranian population. These findings suggest that there is a need
for psychological interventions. An emphasis on increasing and
continuous monitoring of mental health services in the health
centers is recommended. The high and moderate levels of anxiety
and stress in Iranians can negatively affect the well-being and
performance of the population and can lead to serious problems.
Also, a high resilience during negative life events is associated
with well-being. The results of this study can be used to design
psychological interventions. A focus on developing resilience
skills may reduce psychological disorders against the COVID19 pandemic.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by IR.MAZUMS.REC.1399.7293. Written informed
consent to participate in this study was provided by the
participants’ legal guardian/next of kin. Written informed
consent was obtained from the individual(s), and minor(s)’ legal
guardian/next of kin, for the publication of any potentially
identifiable images or data included in this article.
AUTHOR CONTRIBUTIONS
EA, ST, and HS contributed significantly in designing, collecting
data, and writing articles. RE analyzed the data. VK, EF, and
SP were involved in interpreting the findings and reviewing
the manuscript. All authors were read and approved the
final version.
FUNDING
The research leading to these results was financed by the
Mazandaran University of Medical Sciences.
ACKNOWLEDGMENTS
The authors thank all the Iranian people who took part in
this study.
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Anxiety, Hyperarousal Stress, and Resilience During COVID-19 Epidemic
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Copyright © 2021 Sharif Nia, Akhlaghi, Torkian, Khosravi, Etesami, Froelicher
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