DISCUSSION

The noticeable global impact of COVID-19 not only has a strong effect on people who were infected with the coronavirus, but also extends to all people in the affected countries. Iran, being among the first countries after China to deal with the COVID-19 outbreak, and almost 4 mo after the government confirmed the first known case (February 19, 2020), the incidence of the disease in some cities of Iran remains high.^{Reference Abdi6} The (Iranian) government has expressed serious concern about the new waves of the outbreak, during October, November, and December 2020. Given the ongoing rampant nature of COVID-19 and in the absence of special pharmaceutical interventions, changing behavior is the main key to preventing transmission of the virus.^{Reference Tuite, Bogoch and Sherbo3} Understanding the public response and preventive actions to break the transmission chain of COVID-19 during first 3 mo after confirmation COVID-19 in Iran, may help government and health ministry to improve their implication about new waves of the outbreak and new infectious diseases in the future.

Based on the results of this study, engagement in preventive behaviors in the second month of outbreak (March 20 to April 19) considered better than first and third months. Nowruz is the name of the Iranian New Year and occurs on March 21. For 13 days, Iranians celebrate with various traditions, and most importantly, with visiting family and traveling around Iran. Iranian authorities stated that the most important way to control the outbreak on Nowruz is social distancing by reducing traveling, and canceling unnecessary trips, as well as staying at home under voluntary home quarantine.^{Reference Kaffashi and Jahani18,Reference Heidari and Sayfouri19} The health ministry announced that public screening to detect coronavirus would be underway at airports, railway stations, and the city entrances and exits during Nowruz. Also, restrictions have been put in place for all travelers arriving from outside the province and all travel deemed unnecessary has been prohibited.^{Reference Heidari and Sayfouri19} Imposing severe restrictions on traveling during Nowruz is a justifiable reason for improving the respondents’ compliance toward some preventive behaviors such as “staying at home” in the second month of the outbreak. Moreover, improving the respondents’ compliance toward preventive behaviors coincided with a first peak of COVID-19 deaths and new cases in Iran.

According to a report released by the Iranian Health Ministry, the COVID-19 epidemic trend in Iran raised from March 22, 2020, and reached a peak during March 24, 2020, to April 8, 2020. The highest number of coronavirus deaths was recorded during March 15, 2020 to April 15, 2020.^{Reference Roy, Tripathy and Kar4} A study carried out in the United Kingdom found that fear of COVID-19 and its morbidity or mortality rates was an important predictor of positive behavior change.^{Reference Harper, Satchell and Fido20} In the other studies, an association has been found between the perceived severity of disease during an outbreak and carrying out preventive behaviors.^{Reference Morrison and Yardley21,Reference Lau, Yang and Tsui22} In addition to the high morbidity and mortality rate over this period, the government imposed the most restrictions on people traveling, quarantine in cities, and closing public place during this time. Government pressure also seems to have been effective in improving preventive behaviors during second month. Social and governments pressure has been shown to be related to wearing face masks during the outbreak of severe acute respiratory syndrome (SARS)^{Reference Tang and Wong23} and in term of other preventive behaviors, such as personal cleanliness and home hygiene among adults.^{Reference Tang and Wong24} A relationship has been found in Canada between social pressure and compliance with quarantine.^{Reference Cava, Fay and Beanlands25}

Engagement in most of preventive behaviors obviously declined during third month. Engaging in the preventive behaviors is expected to change over the period of the novel coronavirus outbreak because government policies, information about disease, and psychological situation of people change as the virus pandemic develops.^{Reference Wise, Zbozinek and Michelini16} Researches on past outbreaks have shown that negative emotions, such as fear of disease and anxiety, motivate a range of preventive behaviors that reduce the engagement in precarious behaviors. It should be noted that, gradually people cope with fear of new virus and they deal with feelings of anxiety; therefore, a reduction in preventive behavior due to coping of people with fear is predictable. Other studies have shown that anxiety, stress, and fear of infection in the time of pandemic have a functional role, and are related to increased compliance of preventive behaviors. However, long-term stress and fear of corona virus was related to decreased psychological, physical, and social well-being.^{Reference Harper, Satchell and Fido20,Reference Pakpour and Griffiths26} In terms of the psychological impact of COVID-19 outbreak in Iran, a study showed that the severity of psychological distress, such as stress, depression, and mental exhaustion, was high among the Iranian population.^{Reference Vahedian-Azimi, Moayed and Rahimibashar27} It seems that, emotional exhaustion during first 2 mo of coronavirus isolation and easing restrictions during third month played an important role in reducing compliance toward preventive behaviors.

Our analyses indicate that overall compliance toward preventive behaviors was relatively acceptable, and more than 45% of participants always carried out all preventive behaviors. A study carried out in the United States characterized people’s engagement in preventive behaviors over the first week of the COVID-19 pandemic, and the results indicated that most of the subjects reported carrying out the protective behaviors with increasing frequency.^{Reference Wise, Zbozinek and Michelini16} A study carried out in Myanmar found that Myanmar adults have low knowledge and inadequate preventive behaviors to prevent spread of the novel coronavirus. According to their study, only 22% reported good preventive behaviors, 45% of participants frequently wash their hands, 47% of participants always cover the mouth and nose during sneezing or coughing, and just 34% of participants avoided travel. This study indicated that the differences in carrying out protective behaviors between Myanmar and other countries might be due to the lack of knowledge toward the novel coronavirus in this country.^{Reference Murugeswari and Rajeswari28}

Our findings indicate that wearing a face mask in public places and avoiding reusing disposable gloves and masks were in the lowest levels of compliance. It may be due to shortage of face masks and gloves and rising cost of face masks in Iran. In addition to this problem, contradicting recommendations were provided by health authorities on the efficacy of face masks to limit the transmission of COVID-19.^{Reference Marasinghe29} It has been found that there is association between perceived efficacy of behavior and carrying out preventive behaviors during the outbreak of swine flu.^{Reference Rubin, Amlôt and Page30} Studies have found a relationship between perceived efficacy of wearing face masks to protect against influenza and SARS and intentions to carrying out this behavior.^{Reference Lau, Kim and Tsui31-Reference Lau, Yang and Tsui33} An association also has been found between the perceived barriers and costs to protective behaviors and carrying them out. A qualitative study carried out in the United Kingdom found that people experienced some barriers to carrying out protective behaviors in the event of a pandemic, such as shortages of sanitary products or lack of space to keep social distance from other people.^{Reference Abdi6}

Our findings demonstrated that engagement in the preventive behaviors was significantly higher in females and health workers than other participants. Our results were similar to another study during COVID-19.^{Reference Imtiaz, Hossain and Khan34} According to some studies, during a pandemic, compliance rates were associated with some demographic characteristics: females and health-care workers had higher overall compliance scores than males and other occupational groups.^{Reference Imtiaz, Hossain and Khan34,Reference Bish and Michie35} Compared with the general population, health-care providers have higher health literacy as well as, due to duty calls, they are more likely to come in contact with COVID-19 carriers, putting them at a greater risk of contracting the infection and spreading it to others.^{Reference Naser, Dahmash and Al-Rousan36} Therefore, it is to be expected that engagement in the preventive behaviors was significantly higher in the health-care providers than other occupational groups. Moreover, psychological studies showed that the level of COVID-19-related anxiety was higher among women and health-care providers. Studies showed that disease-related anxiety is a powerful motivating factor that increases the engagement in preventive behaviors.^{Reference Wang, Pan and Wan12,Reference Naser, Dahmash and Al-Rousan36}