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Volume 10, Issue 1 (2022)
Health Educ Health Promot 2022, 10(1): 99-107 |
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Received: 2021/09/20 | Accepted: 2021/11/28 | Published: 2022/04/10
Received: 2021/09/20 | Accepted: 2021/11/28 | Published: 2022/04/10
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Psychological Effects of COVID-19 Lockdown on Family Members; a Qualitative Study. Health Educ Health Promot 2022; 10 (1) :99-107
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URL: http://hehp.modares.ac.ir/article-4-55766-en.html
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Table 1) Participants’ characteristics
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Introduction
The COVID-19 pandemic has led to high morbidity and mortality rates as well as many changes and complications in daily life [1]. To reduce the prevalence of coronavirus disease (COVID-19) worldwide, governments urge their citizens to keep their physical distance and stay home to prevent the spread of COVID-19 [2-4]. Nations have implemented locked downs to enforce social distancing as a measure to curb the spread of the infection [5]. This is an effective way to reduce the rate of infection. Contact with fewer people reduces the risk of infection and makes the spread of the coronavirus less likely [6]. Overall, more than 100 countries around the world have had either a full or partial lockdown by the end of March 2020, affecting billions of people [7]. And confining them to their homes [5]. It is estimated that nearly 4 billion people were in social isolation during the April 2020 epidemic [8].
Mboera defines the lockdown as a set of measures to reduce COVID-19 transmission, which is mandatorily enforced by the community and applied indiscriminately to the public [9]. This means that you do not leave the house, except to buy the necessary goods, reduce the number of trips outside the house, and ideally only a healthy family member leaves the house if necessary [10]. Although lockdown minimizes the physical damage of the virus, it may harm the well-being of communities [11]. In the present study, a healthy family is defined as a family in which there no members suffer from COVID-19.
The family is the fundamental unit of all societies [4]. Families are the closest and most powerful source of growth, development, and health for individuals throughout life [12]. Family members rely on each other to varying degrees for emotional, social, and economic support [13]. Family interaction patterns are dynamic and shaped by socio-cultural, economic, and political conditions [4]. Moreover, major traumatic events such as the COVID-19 pandemic can reinforce the positive and negative aspects of interpersonal relationships and lead to competing narratives of injury and reinforcement [14, 15]. The COVID-19 pandemic is a stressor that originates outside the family system, but given the novelty and uncertainty about the disease, it is perceived as a significant stressor for many parents and children [16]. Even families who have not been directly exposed to the virus, are likely to experience the indirect effects of COVID-19 [17]. As COVID-19 continued to spread, it became clear that the virus and its associated problems were not limited to biomedical issues [4], but also led to problems among spouses or other family members, family caregivers, and community primary health care providers. There is such a complex interconnection among these individuals and groups that social distancing and virtual interactions are not effective or adequate [4]. Studies have been published on the increase in domestic violence against women, children, and the elderly and psychological distress during natural disasters and the COVID-19 pandemic [18-22]. There is little knowledge about the effect of the COVID-19 lockdown on the mental health status of families and individuals [23]. Additionally, the dimensions of the psychological experiences of healthy families who were under lockdown are unknown. Given that one of the applications of qualitative research is the discovery of the unknown when we have little information about the target phenomenon, therefore, researchers have used explanatory descriptive qualitative research to investigate the living conditions and experiences of individuals under closure and lockdown during the COVID-19 pandemic. Previous studies have shown that understanding the psychological and behavioral responses to emerging infectious diseases is critical to managing outbreaks [24, 25].
In the present study, a healthy family is defined as a family in which no member suffers from COVID-19.
This study aimed to explain family members’ individual psychological experiences of the COVID-19 lockdown.
Participants and Methods
This qualitative study was a part of a research project done from October 2020 to February 2021 on Public population living in Khorramabad, Iran. The purposive sampling method was used. Sampling began with volunteer participants and new participants were recruited through snowballing of the desired participants with sampling variety from different locations. The sample size reached 29 at data saturation (Table 1). The inclusion criteria were being members of the families with access to the internet and WhatsApp (2020) video chat, The exclusion criteria were having a family member affected member by COVID-19, having a medical history of depression or other psychiatric disorders, or having already been affected by the coronavirus disease or other serious challenges. We recruited healthy family members with different characteristics by purposive sampling since this promoted the rigor of the study.
Unstructured in-depth interviews were used to collect the data. An explanatory descriptive qualitative research [26] was used to evaluate the experiences of the participants under lockdown.
The COVID-19 pandemic has led to high morbidity and mortality rates as well as many changes and complications in daily life [1]. To reduce the prevalence of coronavirus disease (COVID-19) worldwide, governments urge their citizens to keep their physical distance and stay home to prevent the spread of COVID-19 [2-4]. Nations have implemented locked downs to enforce social distancing as a measure to curb the spread of the infection [5]. This is an effective way to reduce the rate of infection. Contact with fewer people reduces the risk of infection and makes the spread of the coronavirus less likely [6]. Overall, more than 100 countries around the world have had either a full or partial lockdown by the end of March 2020, affecting billions of people [7]. And confining them to their homes [5]. It is estimated that nearly 4 billion people were in social isolation during the April 2020 epidemic [8].
Mboera defines the lockdown as a set of measures to reduce COVID-19 transmission, which is mandatorily enforced by the community and applied indiscriminately to the public [9]. This means that you do not leave the house, except to buy the necessary goods, reduce the number of trips outside the house, and ideally only a healthy family member leaves the house if necessary [10]. Although lockdown minimizes the physical damage of the virus, it may harm the well-being of communities [11]. In the present study, a healthy family is defined as a family in which there no members suffer from COVID-19.
The family is the fundamental unit of all societies [4]. Families are the closest and most powerful source of growth, development, and health for individuals throughout life [12]. Family members rely on each other to varying degrees for emotional, social, and economic support [13]. Family interaction patterns are dynamic and shaped by socio-cultural, economic, and political conditions [4]. Moreover, major traumatic events such as the COVID-19 pandemic can reinforce the positive and negative aspects of interpersonal relationships and lead to competing narratives of injury and reinforcement [14, 15]. The COVID-19 pandemic is a stressor that originates outside the family system, but given the novelty and uncertainty about the disease, it is perceived as a significant stressor for many parents and children [16]. Even families who have not been directly exposed to the virus, are likely to experience the indirect effects of COVID-19 [17]. As COVID-19 continued to spread, it became clear that the virus and its associated problems were not limited to biomedical issues [4], but also led to problems among spouses or other family members, family caregivers, and community primary health care providers. There is such a complex interconnection among these individuals and groups that social distancing and virtual interactions are not effective or adequate [4]. Studies have been published on the increase in domestic violence against women, children, and the elderly and psychological distress during natural disasters and the COVID-19 pandemic [18-22]. There is little knowledge about the effect of the COVID-19 lockdown on the mental health status of families and individuals [23]. Additionally, the dimensions of the psychological experiences of healthy families who were under lockdown are unknown. Given that one of the applications of qualitative research is the discovery of the unknown when we have little information about the target phenomenon, therefore, researchers have used explanatory descriptive qualitative research to investigate the living conditions and experiences of individuals under closure and lockdown during the COVID-19 pandemic. Previous studies have shown that understanding the psychological and behavioral responses to emerging infectious diseases is critical to managing outbreaks [24, 25].
In the present study, a healthy family is defined as a family in which no member suffers from COVID-19.
This study aimed to explain family members’ individual psychological experiences of the COVID-19 lockdown.
Participants and Methods
This qualitative study was a part of a research project done from October 2020 to February 2021 on Public population living in Khorramabad, Iran. The purposive sampling method was used. Sampling began with volunteer participants and new participants were recruited through snowballing of the desired participants with sampling variety from different locations. The sample size reached 29 at data saturation (Table 1). The inclusion criteria were being members of the families with access to the internet and WhatsApp (2020) video chat, The exclusion criteria were having a family member affected member by COVID-19, having a medical history of depression or other psychiatric disorders, or having already been affected by the coronavirus disease or other serious challenges. We recruited healthy family members with different characteristics by purposive sampling since this promoted the rigor of the study.
Unstructured in-depth interviews were used to collect the data. An explanatory descriptive qualitative research [26] was used to evaluate the experiences of the participants under lockdown.
Table 1) Participants’ characteristics
The participants' involvement in the study was voluntary and we informed them that they could withdraw from the study without any repercussions at any time. Anonymity and confidentiality of the data were ensured. the data did not have identifiers and were anonymously used in the final report. Only the main researchers had access to the data. Informed written consent was obtained from the participants. Additionally, participants were informed of the objectives and methods of the study, including the need to record the interviews as well as their rights, including the confidentiality of information, anonymity, and the unconditional right to withdraw from the study. Before the interviews, we sent the informed consent forms to the participants electronically. We interviewed them after they gave their consent. The interviews were conducted via WhatsApp video chat and lasted about 20 to 60 minutes and were conducted individually. A voice recorder was used to record the participants’ voices. The primary research question in this study was: “What are your emotional experiences of staying home during the COVID-19 induced lockdown?” Probing questions were asked based on the previous statements of the participants in order to get as much in-depth information as possible i.e. What is your emotional experience of staying home during the COVID-19 lockdown? What is your idea about the negative psychological effects of COVID-19 lockdown in your opinion? What are the positive psychological effects of COVID-19 lockdown in your opinion? How has the COVID-19 lockdown affected you? The interview environment was calm and devoid of disruptive factors. The first author conducted the interviews. With the permission of the participants, all interviews were recorded with a voice recorder and the second author transcribed the recorded interviews verbatim. The interviews were analyzed by the first author and the codes and the coding process were revised by the second author. After analyzing the last interview and extracting its codes accurately, the next interview was conducted. At the same time as conducting the interviews, the interviews were also analyzed. We also asked an expert in qualitative research and a psychologist to review the coding process. Data collection was conducted through unstructured in-depth interviews in a secluded and quiet environment and time at the convenience of the participants. The content analysis approach proposed by Graneheim & Lundman was used to analyze the data [27]. Various types of data can be analyzed by qualitative content analysis, However, in general, before analysis can start, the data need to be transcripted [28]. Accordingly, at the end of each interview, the participants’ recorded statements were repeatedly listened to and their statements were transcribed verbatim. The researchers read each transcribed interview several times to understand the participants’ psychological experiences and perceptions. Then, significant statements and other related statements were underlined to identify meaningful units. Then, each meaningful unit was reduced to a condensed meaningful unit and the initial codes emerged. The first author carefully studied the original codes and categorized them according to the similarity of their concepts as subcategories. During this inductive
process, similar subcategories were classified into main categories. This coding process and the emergence of the main categories were reviewed and discussed by a third experienced researcher. Finally, the obtained categories were considered as expressing the hidden content of the text. The extracted codes were referred to the participants and with their approval, the findings were validated (member check). We provided the participants’ characteristics. The researchers have the required research skills and knowledge to conduct their roles. The researcher also referred the findings and extracted codes to an expert in qualitative research and the validity of the research findings was confirmed (peer check). The coding process and the emergence of the main categories were reviewed and discussed by researchers. The dependability of the findings was achieved by performing the data analysis process by more than one researcher. Researchers tried to put aside their personal experiences and preconceptions in their engagement with the evolving findings and with the data. Moreover, the researchers used the audit trail to establish the confirmability of the study by providing the details of data analysis and some of the decisions that led to the findings. Transferability was ensured by selecting a variety of samples with various demographic characteristics. The researchers tried to make reassurance that both the research conduct and the evaluation were credible and genuine not only in terms of the experiences of the participants but also concerning the wider social and political implications of the research.
Findings
The findings of this study included both positive and negative psychological aspects, each of which had some categories (Table 2).
Negative Psychological Aspects
This theme describes the family members’ experiences of anxiety, a sense of isolation and intensification of loneliness, mood and energy changes, disruption of the sleep-wake patterns, feelings of helplessness, more frequent family disputes and arguments, and increased risk of problematic Internet use and addiction.
Anxiety
This category describes the family members’ experiences with the fear of getting sick, the stress associated with leaving home, obsession with washing, and the stress of staying clean.
All participants experienced stress and fear of infection. This category is one of the key themes that all participants spoke of it. Some participants mentioned overcoming and managing this stress and fear. In particular, two participants in the early stages of the COVID-19 pandemic were pregnant and endured a great deal of stress.
“…We all stayed home and I felt scared, and now little by little it became serious and we observed it. Little by little, we overcame the fear and we began to follow the health protocols.” P2
“The only bad thing that happened during the lockdown was the stress, mostly because of my worries for my baby and my father.” P3
“Two months after I got pregnant, we found out that COVID-19 was prevalent. I was very scared. I had just gotten pregnant. I was scared. It was my first child and I was scared. I did not go out much, just for the ultrasound scan. I was afraid of catching the coronavirus disease.” P2
The participants experienced obsessive-compulsive disorder caused by the stress of the COVID-19 disease. In some participants, the obsession with washing had become a disorder.
“During the lockdown, even though we were inside the house, I always disinfected the bathroom and the whole house regularly, and I had a feeling of stress and anxiety. I used to disinfect the clothes. If we went out, we would hang our clothes outside the house.” P1
“When I breastfed my baby, I washed my hands three times before breastfeeding, and I was really scared.” P2
One participant reported her son’s excessive stress and morbid obsession.
“My son washes his hands regularly and when I ask him to quit this habit, he says a voice in my ear commands me to wash my hands.” P21
A sense of isolation and intensification of loneliness
Participants experienced social isolation, which gave them a sense of loneliness and created or exacerbated feelings of depression.
“We traveled much less, we all observed health protocols, we disinfected the equipment a lot, we kept our distance at home and we sat at a distance from each other.” P2
“My children say we wish to see someone other than ourselves.” P10
The participants reported the feeling of loneliness was exacerbated during the lockdown for old people. They stated this phenomenon has two reasons; Firstly, decreased social relationships cause the exacerbation of loneliness among the elderly. Secondly, family members prefer not to visit older people because they think the older people are weak and may be infected by closer contact. “This lockdown has exacerbated worsened loneliness in the elderly.” P28
Mood and Energy Changes Hardship and Fatigue from Lockdownand Feelings of Boredom: The experience of having a hard time staying home and the resulting boredom was expressed by some family members.
“It was a difficult time. It is not very easy for people who go to work and have a particularly high work efficiency and work hard to be idle, and this causes them to be moody and have a lot of time on their hands without anything to do. This causes boredom and moodiness.” P18
Anger: Some participants stated anger as an experience during the COVID-19 lockdown. It can also have interrelationships with other COVID-19 induced issues such as losing one’s job, decreased income, and lack of entertainment. “It is not tolerable for children and parents to be at home all the time. A person becomes nervous, upset, and sometimes even depressed, and this also hurts the foundation of a good family. Anyway, anger arises, there are conflicts, there are conflicts. In a family, this requires strong management”. P: 11
Depression: Participants experienced depression due to limited recreation and staying at home. Depression can be an outcome of other issues caused by COVID-19 as mentioned above.
“We used to take our son out before the pandemic, but we could not take him anymore. I was depressed, I could not go out anymore. We could not go out to have fun. We have not gone to a place of entertainment at all for 8 months.” P1
“It was a very bad experience and many families became depressed” P27
Feelings of Helplessness
Family members were also tired of the restrictions due to the COVID-19 pandemic and expressed a sense of helplessness. Participant 2, who is a university lecturer said:
“With the prolongation of the COVID-19 pandemic, another damage to the mental health of families is the creation of some kind of helplessness. Helplessness refers to situations in which a person becomes frustrated with lack of improvements in their affairs and lack of control over them, and succumbs to frustration and despair.” P2
The fatigue caused by restrictions led some people to become careless and show disregard for wearing masks and observing social distancing.
“It is hard for me not to have any contact with society. Life has become soulless and un-motivating for me. Sometimes, I get so tired of the lockdown that I go to visit my friends without a mask.” P28
Disruption of the Sleep-Wake Patterns
Participants complained of sleep disturbances during the lockdown, among other issues, such as stress and psychological conditions. This issue had a close relationship with impatience and the difficulty of bearing the lockdown.
“During the lockdown, my sleep-wake pattern has become disrupted.” P28
More frequent family disputes and arguments
Some participants experienced an increase in marital discord during their stay at home due to the lockdown, which led to increased disagreements and arguments in some families due to fatigue from the lockdown and staying at home.
“Marital relationships have changed. Many unspoken things are being said now. Of course, well, these are sometimes good and sometimes positive, but in most cases, it can be said to have a negative effect, unfortunately. And it has weakened relationships.” P17
“Well, the boredom and moodiness caused by the closure affect all members of the family, which somehow reduces the warmth of the relationships in families.” P18
However, some participants stated this experience differently, as they experienced some improvements in family relationships. Participant 9 put it as “a double-edged phenomenon”.
“The effects of staying at home during lockdown were double-edged, and in some cases led to the provision, development, and rapprochement of family relationships, but in other cases it also led to disputes and arguments, according to reports published by the Welfare Organization, referrals for counseling have increased more than before COVID-19.” P29
- Increased the Risk of Problematic Internet Use: From the participants’ point of view, addiction to the Internet and virtual networks was one of the wrong ways of adapting to the lockdown that people used to fill their solitary times with. The participants mentioned that excessive use of the Internet for any purpose, including social networking, can increase the risk of problematic Internet use in children and even lead to addiction to the Internet and digital devices, such as tablets, smartphones, etc., in children.
“On the other hand, those who started using social networks were drawn in a lot more and became more immersed in the virtual world. These are some of the things that result from the lockdown.” P5
The participants worried about the increase in internet use and observe prolonged internet use for online learning or other goals in their children, and predicted the risk of internet abuse or problematic Internet use will increase. Especially if they couldn't manage them clearly.
“As a mother, I cannot determine whether my son is learning virtually or whether he is busy with other things. I sometimes don’t have enough time to control him” P 10
Positive Psychological Aspects
- Movement toward the Expansion of the Worldview: This category describes; understanding the reality of death, taking advantage of the short opportunity of life, developing a sense of helpfulness and cooperation, and understanding the beauties of life and the world)
The participants have had novel experiences during the COVID-19 pandemic and the related lockdown, experiences that had not had ever b
Findings
The findings of this study included both positive and negative psychological aspects, each of which had some categories (Table 2).
Negative Psychological Aspects
This theme describes the family members’ experiences of anxiety, a sense of isolation and intensification of loneliness, mood and energy changes, disruption of the sleep-wake patterns, feelings of helplessness, more frequent family disputes and arguments, and increased risk of problematic Internet use and addiction.
Anxiety
This category describes the family members’ experiences with the fear of getting sick, the stress associated with leaving home, obsession with washing, and the stress of staying clean.
All participants experienced stress and fear of infection. This category is one of the key themes that all participants spoke of it. Some participants mentioned overcoming and managing this stress and fear. In particular, two participants in the early stages of the COVID-19 pandemic were pregnant and endured a great deal of stress.
“…We all stayed home and I felt scared, and now little by little it became serious and we observed it. Little by little, we overcame the fear and we began to follow the health protocols.” P2
“The only bad thing that happened during the lockdown was the stress, mostly because of my worries for my baby and my father.” P3
“Two months after I got pregnant, we found out that COVID-19 was prevalent. I was very scared. I had just gotten pregnant. I was scared. It was my first child and I was scared. I did not go out much, just for the ultrasound scan. I was afraid of catching the coronavirus disease.” P2
The participants experienced obsessive-compulsive disorder caused by the stress of the COVID-19 disease. In some participants, the obsession with washing had become a disorder.
“During the lockdown, even though we were inside the house, I always disinfected the bathroom and the whole house regularly, and I had a feeling of stress and anxiety. I used to disinfect the clothes. If we went out, we would hang our clothes outside the house.” P1
“When I breastfed my baby, I washed my hands three times before breastfeeding, and I was really scared.” P2
One participant reported her son’s excessive stress and morbid obsession.
“My son washes his hands regularly and when I ask him to quit this habit, he says a voice in my ear commands me to wash my hands.” P21
A sense of isolation and intensification of loneliness
Participants experienced social isolation, which gave them a sense of loneliness and created or exacerbated feelings of depression.
“We traveled much less, we all observed health protocols, we disinfected the equipment a lot, we kept our distance at home and we sat at a distance from each other.” P2
“My children say we wish to see someone other than ourselves.” P10
The participants reported the feeling of loneliness was exacerbated during the lockdown for old people. They stated this phenomenon has two reasons; Firstly, decreased social relationships cause the exacerbation of loneliness among the elderly. Secondly, family members prefer not to visit older people because they think the older people are weak and may be infected by closer contact. “This lockdown has exacerbated worsened loneliness in the elderly.” P28
Mood and Energy Changes Hardship and Fatigue from Lockdownand Feelings of Boredom: The experience of having a hard time staying home and the resulting boredom was expressed by some family members.
“It was a difficult time. It is not very easy for people who go to work and have a particularly high work efficiency and work hard to be idle, and this causes them to be moody and have a lot of time on their hands without anything to do. This causes boredom and moodiness.” P18
Anger: Some participants stated anger as an experience during the COVID-19 lockdown. It can also have interrelationships with other COVID-19 induced issues such as losing one’s job, decreased income, and lack of entertainment. “It is not tolerable for children and parents to be at home all the time. A person becomes nervous, upset, and sometimes even depressed, and this also hurts the foundation of a good family. Anyway, anger arises, there are conflicts, there are conflicts. In a family, this requires strong management”. P: 11
Depression: Participants experienced depression due to limited recreation and staying at home. Depression can be an outcome of other issues caused by COVID-19 as mentioned above.
“We used to take our son out before the pandemic, but we could not take him anymore. I was depressed, I could not go out anymore. We could not go out to have fun. We have not gone to a place of entertainment at all for 8 months.” P1
“It was a very bad experience and many families became depressed” P27
Feelings of Helplessness
Family members were also tired of the restrictions due to the COVID-19 pandemic and expressed a sense of helplessness. Participant 2, who is a university lecturer said:
“With the prolongation of the COVID-19 pandemic, another damage to the mental health of families is the creation of some kind of helplessness. Helplessness refers to situations in which a person becomes frustrated with lack of improvements in their affairs and lack of control over them, and succumbs to frustration and despair.” P2
The fatigue caused by restrictions led some people to become careless and show disregard for wearing masks and observing social distancing.
“It is hard for me not to have any contact with society. Life has become soulless and un-motivating for me. Sometimes, I get so tired of the lockdown that I go to visit my friends without a mask.” P28
Disruption of the Sleep-Wake Patterns
Participants complained of sleep disturbances during the lockdown, among other issues, such as stress and psychological conditions. This issue had a close relationship with impatience and the difficulty of bearing the lockdown.
“During the lockdown, my sleep-wake pattern has become disrupted.” P28
More frequent family disputes and arguments
Some participants experienced an increase in marital discord during their stay at home due to the lockdown, which led to increased disagreements and arguments in some families due to fatigue from the lockdown and staying at home.
“Marital relationships have changed. Many unspoken things are being said now. Of course, well, these are sometimes good and sometimes positive, but in most cases, it can be said to have a negative effect, unfortunately. And it has weakened relationships.” P17
“Well, the boredom and moodiness caused by the closure affect all members of the family, which somehow reduces the warmth of the relationships in families.” P18
However, some participants stated this experience differently, as they experienced some improvements in family relationships. Participant 9 put it as “a double-edged phenomenon”.
“The effects of staying at home during lockdown were double-edged, and in some cases led to the provision, development, and rapprochement of family relationships, but in other cases it also led to disputes and arguments, according to reports published by the Welfare Organization, referrals for counseling have increased more than before COVID-19.” P29
- Increased the Risk of Problematic Internet Use: From the participants’ point of view, addiction to the Internet and virtual networks was one of the wrong ways of adapting to the lockdown that people used to fill their solitary times with. The participants mentioned that excessive use of the Internet for any purpose, including social networking, can increase the risk of problematic Internet use in children and even lead to addiction to the Internet and digital devices, such as tablets, smartphones, etc., in children.
“On the other hand, those who started using social networks were drawn in a lot more and became more immersed in the virtual world. These are some of the things that result from the lockdown.” P5
The participants worried about the increase in internet use and observe prolonged internet use for online learning or other goals in their children, and predicted the risk of internet abuse or problematic Internet use will increase. Especially if they couldn't manage them clearly.
“As a mother, I cannot determine whether my son is learning virtually or whether he is busy with other things. I sometimes don’t have enough time to control him” P 10
Positive Psychological Aspects
- Movement toward the Expansion of the Worldview: This category describes; understanding the reality of death, taking advantage of the short opportunity of life, developing a sense of helpfulness and cooperation, and understanding the beauties of life and the world)
The participants have had novel experiences during the COVID-19 pandemic and the related lockdown, experiences that had not had ever b