Stress Coping Styles in Family and Relatives of Coronavirus Disease 2019 (COVID-19) Patients in the South of Iran: Application of Lazarus and Folkman’s Theory of Stress Coping

: Background: The ongoing outbreak of Coronavirus disease 2019 (COVID-19) is a major challenge for mental health care systems and causes and exacerbates mental anxiety. Objective: This study sought to investigate the coping styles of stress in families and relatives of COVID-19 patients in the south of Iran, according to Lazarus and Folkman’s Transactional theory of Stress coping model. Methods: The present cross-sectional study was performed in the period from March 5 to July 5, 2020. Data collection was done electronically using a standard questionnaire on Lazarus and Folkman’s coping methods. Finally, the output data of the electronic questionnaire were analyzed using descriptive and inferential statistics.


INTRODUCTION
The rapid spread of COVID-19, severe infection, death in severe cases, and the lack of specific drugs for treatment pose a threat to human life and health, and also have a great impact on mental health, while individuals differ in the degree of emotional problems. Therefore, it can be predicted that the prevalence of COVID-19 would contribute to general psychological reactions, such as stress, anxiety, and fear, facilitating mental disorders, such as acute stress disorder, posttraumatic stress disorder, depression, and suicide [1,2]. Although infectious diseases produce a wide range of emotional responses, not all people experience the same amount of emotional impact and have different coping strategies, as people did during the MERS-CoV outbreak in which perceived stressors and coping strategies were different [1].
Stress is the physiological response of the body to any kind of change, threat, or internal and external pressure, that causes mental imbalance, and stress is an inevitable event in everyone's life [3]. In COVID-19, as a potential source of psychological crises, stressors can include longer quarantine, fear of infection, frustration, boredom, insufficient resources, insufficient information, financial loss, and fear of being labeled [4]. Also, intervention in psychological crises should include two simultaneous activities: (1) intervention for fear of illness and (2) intervention for adaptation problems to prevent and manage violence and suicidal behaviors [5]. Therefore, awareness of psychological reactions and perceptions among the general public during an epidemic can determine the severity of the risk and the need for mental health interventions [6]. Therefore, before implementing interventions, it is necessary to examine the status of the effect of stressors on individuals and how people adapt to these stressors. One of the models that examine the adaptation of people to stressors is the transactional stress model of Lazarus and Folkman. The Folkman transactional model has the structures of primary evaluation, secondary evaluation, stress, and adaptation. In discussing the initial assessment, the individual may assess the situation as threatening or, conversely, harmless. The second stage, or secondary evaluation, examines the type of action that the individual should take about that situation or environment. The sense of danger and the extent of it depends on the possibilities that the person feels they have, and this is related to the information that the environment, life experiences, and personal characteristics have yielded. New information may be effective in reassessing a person's situation and re-evaluating it. Indeed, in Trougakos et al., the authors examined the stress and anxiety caused by COVID-19 using Lazarus and Folkman's Transactional theory and the theory of self-determination at work, home and health [7]. Their model predicts that a form of problem-focused coping-will mitigate the effects of COVID-19 anxiety. Additionally, according to Trougakos, anxiety and stress due to Covid-19 were found to impair critical work (goal progress), home (family engagement) and health (somatic complaints) causing increased emotional suppression and lack of psychological need fulfillment.
Thus, the main assumption of the Lazarus-Folkman interactive model is that primary assessment, secondary assessment, and coping strategies mediate between stressors and the consequences of stress in individuals [8,9]. The results of Morowatisharifabad et al., who used the Lazarus and Falkman model on stress in hemodialysis patients showed the subcategories of perceived susceptibility, perceived severity, and casual focus were the most effective factors in the stress appraisal in HD patients. Indeed, patients need help to improve their evaluation in subcategories of motivational relevance, perceived control over outcomes, perceived control over emotion, and self-efficacy. In this regard, one of the best models that can be used to identify the appraisals in patients is Lazarus and Folkman's Transactional theory [10]. The study by Anderson et al. copes with aging [11] and the studies by Ma et al. [12]. and Crowe BM et al. [13] cope with stressful work conditions and job motivation, emphasizing the effect of Lazarus and Folkman's transactional theory on stress. Thus, past studies in different countries show that Lazarus and Folkman's transactional theory can be effective against stress in different situations, places and people.
In Wang's study, 16% of participants in the study had moderate to severe depression. About 28.8% had moderate to severe anxiety and 18% had moderate to severe stress due to the psychological impact of COVID-19. In Huang's study, the closer COVID-19 was to participants (contact with patients), the stronger the anxiety and anger. In the Al-Rabiaah , s study, stress levels were significantly related to generalized anxiety disorder [1,2]. There is currently limited information on factors pertaining to how people cope with the stress of the COVID-19 epidemic, especially based on psychological theories. Moreover, there is no study regarding the adaptation of stress in those around the patient using the interactive stress model of Lazarus and Folkman, therefore, this study sought to investigate the coping styles of stress in families and relatives of COVID-19 cases in the south of Iran, according to Lazarus and Folkman's Transactional Theory of Stress coping model.

The Study and Setting
This cross-sectional study was performed on the relatives of patients with COVID-19 between the period of March 5 to July 5, 2020.

Sampling
This study was performed on 276 participants. The inclusion criteria for the study participants were having COVID-19, patients' family members, and relatives in the South of Iran.

Data Collection
Data collection was done virtually in 7 cities in the south of Kerman province, Iran. The demographic questionnaire and standard questionnaire on Lazarus and Folkman's coping methods, which consisted of 66 questions, were used electronically to collect data. The purpose of this questionnaire is to assess people's thoughts and actions to cope with stressful life events. In the Lazarus and Folkman questionnaire, the answers are of the four-choice Likert type and it includes I did not use (score zero), I used to some extent (score 1) I used it most of the time (score 2) and I used it a lot (score 3). This questionnaire includes eight domains of confronting coping (score 0 to 18), distancing and positive reassessment (scores 0 to 21). The domains confronting coping, distancing, selfcontrolling, and escape-avoidance are related to the emotioncentered coping styles considered undesirable, and the areas of seeking social support, accepting responsibility, planful problem solving, and positive reassessment are problemoriented coping styles. To calculate the scores in each domain in the case of problem-oriented coping style domains, a score of less than 50% achievable score was considered weak, between 50 to 75% of the average achievable score was moderate and a score above 75% of the achievable score was considered good. Also, to classify the scores in each domain for the areas of emotion-oriented coping styles, obtaining a score less than 50% of the achievable score yielded a classification of 'well', between 50 to 75% was 'moderate', and obtaining a score above 75% was considered 'weak'. In Alipour et al., the reliability of this assessment was 0.85 [14].
In the Folkman and Lazarus study, the internal consistency was 0.75, and the reliability of its subdomains was 0.61 for distancing coping style, and up to 0.79 for positive reappraisal [15]. Also, in the research of Agha Yousefi et al., the reliability of the questionnaire was calculated in the sample using Cronbach's alpha and a coefficient of 0.76 was obtained, which indicates the high reliability of the questionnaire [16].

Ethics Approval
This project acquired ethical committee approval from the Jiroft university of medical science (IR.JMU.REC.1399.003).
All research was conducted in accordance with the ethical standards of the Institutional Research Committee and with the 1964 Helsinki declaration and its latest amendment.

Statistical Analysis
The output data of the electronic questionnaire were entered into SPSSv18 software and analyzed using descriptive statistical tests, independent t-test, and ANOVA.

RESULTS
Overall, 276 people participated in the study, and 67.8% of them were in the age group of 41-60 years. The majority of participants in the study (51.8%) were women, and the occupation of the majority (72.1%) was recorded as employees. In terms of education, 47.1% had a diploma, 92.4% were married, and 69.9% lived in the city. Regarding the symptoms of the disease, the highest percentage was related to asymptomatic (34.8%), followed by fever (33.7%), shivering (23.9%), cough (15.2%), and apnea (13.8%).
The domains of seeking social support, positive reappraisal, and self-controlling, with an average percentage above 50%, had the highest scores in Table 2. In terms of the difference in the mean score of domains related to emotionoriented coping style, according to some specific variables in this study, there was a significant difference between age and all domains, except emotion-oriented coping style itself, literacy, and self-controlling (P <0.05) ( Table 3).
In terms of the difference in the mean score of areas related to problem-oriented coping style, there were significant differences (P <0.05) related to age and seeking social support and accepting responsibility, literacy and all domain and the problem-oriented coping style itself, source of information and all domain and problem-oriented coping styles itself, symptoms of disease and accepting responsibility, planful problem solving positive reappraisal and problem-oriented coping styles, smoking and planful problem solving positive reappraisal, and problem-oriented coping styles, ( Table 4).

DISCUSSION
The results of the present study indicate that, from the emotion-oriented coping styles, the domain of self-controlling received an unfavorable score, but in the problem-oriented coping styles, the two domains of seeking social support and positive reappraisal obtained a moderate to high and desirable score, respectively. The results of the present study were in line with the study of Agha-yousefi [17 -19] in terms of seeking social support. Moreover, in Morowatisharifabad et al., social support was emphasized as the most important source to reduce stress and depression [20]. In explaining these results, it is likely that this disease causes changes in physical condition, severe psychological issues, reduced duration of recreational activities and social communication, and therefore, having social support and positive reappraisal can be a great way to alleviate stress. The results of the present study showed that positive reappraisal had a high mean; that finding is similar to the results of Faryabi and Ghaffari [17,21]. Positive reappraisal increases the level of confrontation and can increase mental health [22], and as a self-regulatory source, can increase positive effects and reduce negative effects [23]. In terms of the domain of self-controlling, the results of the present study were inconsistent with the study of Golchin [18]. Indeed, it can be hypothesized that the presence of COVID-19, as compared to other previous studies, contributed to an ineffective control of emotions, hurried handling of events, and loss of focus on the situation and coping with the disease. In terms of the difference in the mean score of domains related to emotion-oriented coping style, we noted a significant difference between age and all domains (P <0.05).
There was also a statistically significant difference in emotion-oriented coping styles between the domains of selfcontrolling and escape-avoidance according to demographic variables. However, in the emotion-oriented coping style, there was a statistically significant difference between the field of distancing according to literacy, source of information, disease symptoms, and smoking. The study by Fu et al., showed that 29.8% of the participants in the study had a negative emotional response to COVID-19, and there was a statistically significant relationship between passive coping style in the face of COVID-19 and literacy [24]. The results of our study showed that underlying disease, smoking, and symptoms of the disease were associated with emotion-oriented coping styles, which was consistent with Alizadeh et al. [25]. Severe symptoms, such as body aches, fever, and lung involvement, appear to cause family and relatives to think about the disease and their condition; in both studies [24,24], people with worse symptoms and underlying disease tend to deny and avoid the stressful situation [25].
When individuals imagine themselves exposed to an untreated situation and face illness and a long course of treatment; they are more likely to use an emotion-oriented strategy [21]. In Mohammadkhani [26], there was an inverse relationship between emotion-oriented style and students' general health. In the present study, the escape-avoidance domain was a notable variable for exposing the stress status of families and relatives against COVID-19. The results of Gerin et al. [27] also showed that, out of the eight domains of coping styles, only the escape-avoidance domain was a useful variable for predicting coronary heart disease. Avoidance coping style, which is a negative and emotional way of dealing with stressful life events, prevents the expression of feelings and emotions and facilitates emotional inhibition, and is a risk factor that predisposes a person to coronary heart disease [28]. Age, source of information, and literacy of individuals were identified as effective components in the problem-oriented style (P <0.05(. The results of Ghazanfari et al., showed that there was a significant relationship between mental health and coping strategies. Indeed, the more a person uses a problembased coping strategy, the healthier they appear to be, and conversely, an emotion-oriented coping strategy increases physical symptoms, anxiety, social dysfunction, and depression [29]. However, in our study, the presence or absence of disease had no effect on the use of coping styles. Therefore, improving people's literacy and paying attention to the source of information, such as using social networks and supporting family, friends, and health workers, can help people deal with the problem and reduce stress in people. In our study, there was no apparent relationship between age, gender, and marital status and coping strategies, whilst in the study by Nguyen et al. [30], age, gender, social class, and personality traits were influential factors in coping strategies. The use of checklists and different populations in the two studies may be a cause of discrepancy. In the present study, literacy was identified as an influential variable in the use of problem-oriented coping strategies, but in Nguyen et al. [30], social class was associated with coping strategies. Typically, people with higher education are in a higher social class, and therefore, in stressful situations, they tend to use more problem-solving coping strategies. In the problem-oriented coping strategy, planful problem solving and positive reappraisal was more commonly used. In Wu et al. [31], in concordance with our findings, the authors showed that the use of a problem-solving coping strategy is an important factor in the association between anxiety and depressive symptoms and the change in substance use. So, people who are more resilient tend to employ problemoriented coping strategies and use problem-solving skills, counseling, and goal-setting skills in difficult situations, such as severe symptoms of disease and smoking.
Due to the severe global situation, COVID-19 posed a great threat to families and was viewed as uncontrollable in the early period of the disease, causing people to suppress their emotions and follow an emotion-oriented coping approach. By suppressing emotions, the destructive effect on people increases [32]. Indeed, in Reeve et al. [33], the use of two strategies of problem solving and focus on emotion was identified as effective guides against stress. In Alexander and Harrison [34], low effect and ineffective strategies, such as distancing were mentioned as vulnerable factors against stress, whilst in Sudraba [35], addicts used the emotion-oriented coping strategy more, but in our study, smoking in family and friends was associated with both strategies. Different populations and the presence of COVID-19 can affect the choice of strategy in individuals. Indeed, emotion-oriented coping focuses on controlling emotional distress and focuses on the emotional factors associated with it, not the situation itself. Instead of coping, these individuals tend to experience problems. Negative life events, perceived stress, more use of negative coping techniques, anger, and helplessness, and less use of positive coping techniques and cognitive coping are significantly and independently associated with smoking and drug use [36].
In terms of coping style or type of adaptation, smoking has been recognized as an important factor that may be associated with both types of coping styles. In Gan et al., a passivemaladaptive pattern prevailed when dealing with stressful events in daily life [37]. In addition, study participants who showed less differential ability to control situations related to stressful events in daily life showed a weaker strategy for coping with SARS-related events than stressful events in daily life [37]. This could be the case with COVID-19 due to the prevalence of false beliefs and rumors on social media and in society about the protective effect of alternative therapies, e.g., opium use [38].
The use of both types of coping styles depends on the level of social support in addicts. Indeed, the usefulness of social support may affect the subjective assessment of stressors, the choice of effective coping strategies, self-esteem, and individual skills. Previous studies have shown that people with high social support are more resilient in the face of stressful life events and use better coping methods [39]. In other words, inefficient coping of family and relatives with stressors in the long run has negative consequences, such as depression, anxiety, and drug use. Conversely, people who choose a more appropriate coping style are more likely to have broader social support and better mental health, and, as a result, are less likely to be exposed to drugs and have problem-solving skills in stressful situations.

LIMITATIONS
Although we present a novel addition to the literature, there are numerous limitations of the present study that should be considered 1: Patients' families did not cooperate fully in completing the questionnaires due to stress and anxiety about the disease. 2: Questionnaires were completed virtually; a number of people did not have electronic devices or facilities, and also had not been taught how to work with it. 3: The present study was conducted in southern Iran only, which harms its' national and international generalizability.

CONCLUSION
In the present study, the escape-avoidance coping style, planful problem solving, and positive reappraisal were useful variables for the prediction of the stress status of families and relatives.
Therefore, given the importance of the Lazarus and Folkman model, it is recommended that providing structured education to families and others, can markedly reduce stress. Moreover, by using coping techniques, this confidence and resilience increased in families, providing very favorable and calm conditions for the care of COVID-19 patients. Therefore, in addition to medical and psychological interventions for patients with COVID-19, psychological interventions for those around them and their caregivers, such as teaching coping strategies, seems necessary.

AUTHORS' CONTRIBUTIONS
Conceptualization was done by R.F and E.M. Data curation was done by S.D and T.R. Formal analysis was conducted by A.Y. Investigation was done by MSH.K. Methodology was selected by D.C and S.A. Project administration was done by A R.F and E.M. Writing the original draft was done by E.M and R.F, and review & editing were done by A.Yand MSH.K. All authors have read and agreed to the published version of the manuscript.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This project acquired an ethical Committee approval from the Jiroft University of Medical Science (IR.JMU.REC.1399 .003).

HUMAN AND ANIMAL RIGHTS
No animals were used for studies that are the basis of this research. All the humans were used in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013 (http://ethics .iit.edu/ecodes/node/3931).

CONSENT FOR PUBLICATION
Informed written and verbal consents were taken from all participants prior to data collection.

STANDARDS OF REPORTING
STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of the article is available from corresponding author [E.M] upon reasonable request.

FUNDING
None.