Mourning During COVID-19 Pandemic in Bojnurd, a City in Northeast of Iran: A Qualitative Study

Abstract
Background: The way one mourns varies across different cultures. As such in each society, the mourning rituals in accordance with the culture of that society can alleviate the grieving process. During the coronavirus (COVID-19) pandemic, in many parts of the world, restrictions have been imposed on hosting different ceremonies and events to control the spread of the virus. Since the enforced regulations have made changes to the way mourning is done in these times, an investigation of the experiences of people of different cultures in coping with loss during the current crisis seems to be of importance. The purpose of this study was to investigate the mourning experiences in north-east of Iran during COVID-19.
Methods: This is a qualitative study which was conducted by using content analysis. The participants were 11 individuals who had lost a family member due to COVID-19 in Bojnurd in 2020. Sampling was purposive and continued until reaching data saturation. Semi-structured interviews and note-taking were utilized for data collection. The interviews were recorded and the notes were then evaluated.
Results: After analyzing the collected data and forming semantic units, three main categories and nine sub-categories of unexpressed grief were extracted. Unexpressed bereavement, effects on mental health, and dissatisfaction with services comprise the main categories while lack of farewell opportunity, the emotional burden of COVID-19, strange burial, fear and social stigma, lack of adequate psychological support, emotional trauma and shock, reducing the motivation for life, lack of professional principles in the death announcements, and finally lack of equipment and non-compliance with hygiene standards make up the 9 subcategories.
Conclusion: The collected evidence concerning the unexpressed grieving experience ensuing from the COVID-19 induced death of a family member reveals such issue to be one of the most important mental health issues during the spread of the virus, which requires the necessary investigation and intervention of the experts in this field.
Keywords: COVID-19, Grief, Iran, Pandemics
Introduction
Coronavirus (COVID-19) began in Wuhan, China, in late 2019 and has since then been rapidly spreading on a global scale (1). Studies conducted during this period are indicative of many pandemic-induced health-related, social, and economic complications and occasionally of irreparable ramifications in societies (1-3). In addition to making changes to conditions of living and lifestyles – i.e. imposing restrictions on relationships, occupations, ceremonies, pastimes, and education–, COVID-19 has negatively impacted the mental health of individuals and societies by increasing the mortality rates. Studies have reported high rates of anxiety, depression, and post-traumatic stress disorder associated with this pandemic (4).
According to the statistics reported in Iran, 91,000 people have died from COVID-19 (5), which indicates many people’s involvement in the process of bereavement and other experiences related to the loss of the loved ones. The experience of losing a loved one is one of the most stressful events in a person’s life (6,7). One of the factors facilitating the process of bereavement and loss of loved ones is proper mourning. Accordingly, in Iranian culture, burials and funerals include elaborate customs and religious rituals that can yield soothing effects (8). 
In Iran, mourning ceremonies are comprised of specific sequence of customs, namely funeral procession, burial of the deceased in presence of his/her friends and relatives, the relatives’ gathering in the deceased’s home to console the bereaved family, hosting a religious ceremony, and doing charity on behalf of the deceased. At the same time, in Iran, like in other countries, newly enforced policies and instructions regarding the management of corpses, funerals, burials and attending other customary rites are being implemented (9). As a consequence of the imposed restrictions, families who have lost loved ones have often been deprived of the chance to attend the person’s bedside before his/her death, hence missing the opportunity to bid farewell to the deceased. Restrictions on ceremonies such as farewells and funerals, and other ceremonies  in which the bereaved can benefit from the support of those around them, as was the case prior to the restrictions, have caused those who have lost their loved ones to feel unresolved grief and fail to fully express it (8,10,11).
Moreover, when a person is likely to die of an illness and a particular condition, his/her relatives would experience emotional reactions caused in anticipation of the imminent death. Such reactions are expected behavioral and emotional consequences and can be described as preliminary bereavement, otherwise known as anticipatory grief (12). Anticipatory grief allows those close to the deceased to psychologically prepare themselves for the impending loss, to alleviate the process of adaptation to bereavement, and to pass the grieving and mourning stages –which consist of appropriate cognitive, emotional, and behavioral reactions– as  natural responses to loss and a psychological process (13). However, during the COVID-19 pandemic, many people have unexpectedly and suddenly lost their relatives within just a week or two following the person’s disease, and they are thus left facing problems such as unresolved bereavement.
According to the studies in this field, when people do not have the opportunity to adjust and respond to the loss of their companions or have access to social support, a disturbance appears in the natural response to sadness, leading to the persistence of painful feelings in long term (14,15). Accordingly, the COVID-19 pandemic seems to have further complicated the challenges of the mourning process. In such circumstances, unexpressed and unresolved sorrow and grief in response to one’s loss can cause severe sadness and other maladaptive emotions in the long run, thus causing one to experience the loss for months or even years (10).
To support these bereaved individuals, we need to gain a deep insight into their lived experiences in the face of such sudden losses. To do this, we study the experiences of people who have lost their families as a result of COVID-19, using a qualitative approach and content analysis methods. A deep understanding of how they have experienced and faced the loss and bereavement is required to identify their psychological needs and provide them with appropriate services to help reduce the psychological damage caused by not expressing bereavement in such conditions as well as to identify the appropriate strategies to increase social and health support.
Materials and Methods
Due to the exploratory nature of this study, a qualitative methodology based on content analysis was used. Content analysis is a systematic coding and classification approach commonly used to examine and clarify concepts, words, and phrases within the text. 
Purposive sampling continued until reaching data saturation. This study was performed in the third wave of the pandemic in Iran and there was no vaccine for COVID-19 at that time. Participants were selected from family members of people who had died of COVID-19 in North Khorasan province. Having had real bereavement experiences, the family members of the deceased were selected taking into account their diversity in terms of age, gender, marital status, educational level, and family relationships with the deceased. The present study was conducted from June 2020 to December 2020 in North Khorasan, north-east of Iran.
Data were collected using semi-structured interviews and they were also listed in the table. The interviews were conducted by a clinical psychologist. Initially, some questions were asked to get to know the participants and create a friendly atmosphere. The interview was then directed toward the purpose of the study, and the participants were asked to provide answers based on their unexpressed bereavement experiences following the loss of their family members. 

Some of the questions raised include
1- Do you mind telling us about what happened to you and your family?
2- How was other people and relatives’ relationship with you during the bereavement?
3. Were you allowed to visit your patient?
The interviews were conducted through telephone calls, each lasting 15 to 30 minutes. Then, according to the given answers, a few questions were asked for the sake of further exploration and discovery. ‘Can you give an example?’ and ‘Can you explain more?’ are two instances of such questions. Interviewing to collect and record data continued to the point of data saturation; that is to say, they continued until no more new data was added. Data analysis was performed based on Granheim and Landman content analysis (14). 
The interviews were recorded as notes and entered into MAXQDA qualitative analysis software version 2018. For a better understanding, after semantic units were extracted from the interviews, they were then coded. Afterwards, categories and sub-categories were extracted therefrom. Next, hidden contents and concepts were constructed and used as sub-categories. Finally, some participants and experts exchanged views on the obtained factors and compared the relevance thereof. To review, confirm, and reach a consensus, the obtained results were controlled by people who were knowledgeable regarding qualitative research and bereavement experiences.

Results
The subjects in this study were 11 individuals with grief experience of the loss of a family member. Women comprised 64% of the subjects in this study (Table 1). Three main themes in relation to mourning during COVID-19 were identified, namely unexpressed bereavement, effects on mental health, and dissatisfaction with services. Each of these themes takes different and various sub-categories. An example of this qualitative analysis is given in table 1 and the details of the data analysis are shown in figure 1.

Table 1. Demographic Characteristics of Percipients

A. Unexpressed bereavement
A.1. Lack of farewell opportunity
Lack of time to see and be close to the deceased member of the family, as well as loss of the last chance to bid farewell are among the sentences associated with this category. The family may not have seen their loved ones long before she/he is on the deathbed, but being near him/her reduces the burden of their grief. Many families who were away from their patients at the time of death felt guilty about the missed opportunities and having spent the last days away from the deceased; they would think that if they were with the deceased, they could have relieved the pain and empathized with him/her. It is these thoughts that make it more difficult to overcome the darkness and heaviness of the days of mourning and grief. The death of a loved one, even if he/she dies of an illness, is hard to believe since the family have not been in close contact with the diseased person to see the manifestation of the disease and have not been present at his/her bedside at the time of death. All of these make it more difficult for them to believe the death of a family member.
The daughter of one of the Coronavirus victims stated:
“When I woke up, I saw my mother being taken to the morgue. I asked who had died. They said: ‘Your mother died and her body was taken to the morgue.’ Shouldn’t her family be informed when she is not well? If I had known, I would have called my old father and my family to talk to my mother on the phone.”

A.2. The emotional burden of COVID-19
 The emotional burden of COVID-19’s consequences has a huge impact on the mental health of the members of a community. Directly and indirectly, COVID-19 can cause psychological problems for individuals. Proper mourning is a way to resolve the grief of a person by allowing emotional purgation. However, in the current situation during which people are unable to perform routine ceremonies and even benefit from close friends’ sympathy, unresolved grief occurs. Prohibition of performing funeral ceremonies and other death-related customs brings unpleasant feelings of remorse and guilt on the bereaved family. Besides struggling with the absence of their loved ones, these families must carry this burden on their own deprived of the possibility to hold mourning ceremonies and hug those around them, which can reinforce the healing of their wounds. People start contemplating over what they wanted to say to or do for the deceased. They might even think of what they could have done better if they had done things differently. Participants explained that some of the pains caused by the absence of the loved one manifest in the form of mental shock and denial of the person’s death. When a family member develops a disease, other members are also in a distressing and difficult situation; therefore, the financial resources, time, and mental energy of all the members are fully affected.
"In such times, when we are in the mourning period and have lost a loved one, yet we are still living our lives, how could we possibly be expected to endure all this?”

A.3. Strange burial
Funerals and burials in the most tragic way possible, painful farewells to a family member, changes in the ways ceremonies are held, feeling bad over not having washed the dead, the unpleasant feeling ensuing from the failure to do charity and to pay for the ceremony, not offering sympathy or the fear of expressing more sympathy on the part of friends and relatives during funerals, and fear of approaching the family members of the infected resulting in offering cold comfort, loneliness of the bereaved during funerals and burials are among the issues discussed in this regard. Not holding funeral ceremonies to which people can attend makes it impossible for many to move on with their lives. The subjects of this study had found the funerals very tragic since people’s attendance in the funerals was far from what was considered normal and they were not in good mental and physical states.
“When they brought my mother’s body to the village, they did not even allow us to hold a mourning ceremony for my mother.”
“No one came to the funeral. There was no one but 7-8 members of our family. They also did not allow us to see the body for one last time. They took him straightaway and buried him. No one came to express sympathy. We were alone.”

B. Effects on mental health
B.1. Fear and social stigma
 The rapidly increasing number of COVID-19 patients along with the public’s lack of awareness about the virus has caused fears and concerns among people, leading to challenges such as social stigma. One of the psychological and social consequences of the outbreak of some diseases, especially communicable ones such as COVID-19 in any society is the fear of social reactions, stigma, and transmission, thus affecting different aspects of life due to their high prevalence. The COVID-19 outbreak also involves people in a series of anxiety disorders such as the fear of getting sick and dying, transmitting the disease to another person, developing the disease as a result of social interactions or contacting objects, and being in public places. 
Due to the contagion of COVID-19, people refuse to go to medical centers and hospitals. Family members are even concerned about how people around them have been treated, for such phenomenon has been hitherto unprecedented; therefore, this new unpleasant situation has made these people and those around them face the absence of correct behavioral and emotional reactions. As it was repeatedly pointed out by the participants, the COVID-19 outbreak has caused fear among people about attending funerals. The living relatives and friends need to accompany the bereaved families to relieve their grief; the lack of such companionship, even from close relatives, makes it tougher for the bereaved to deal with the grieving process.
«People were completely freaked out. They wouldn’t even come near us. At first, people were terrified to the point that they would come up with stories about where the deceased would be buried whatever would be done to the bodies and what not. We were ourselves shocked to hear all that.”

B.2. Lack of adequate psychological support
Those who lose loved ones during the COVID-19 outbreak are forced not to hold ceremonies, and are thus left struggling with the ensuing unpleasant psychological effects. For example, not holding ceremonies or not attending funerals has caused many people to still feel attached to the deceased. A corollary of one’s inability to move on and accept the absence of the deceased is manifest in the individual’s eventual distance from reality.
The husband of one of the Coronavirus victims asserted:
“In the village, my mother-in-law could not leave the house. People said we are carriers of the virus, no one should approach us and we had to distance ourselves. They behaved in such a way that made us feel ashamed. All the same, we did not complain and did what they said.”

B.3. Emotional trauma and shock
One of the important effects of the COVID-19 outbreak on societies has been making changes to people’s lifestyles, specifically those facing the death of their loved ones. The sudden death of people in these circumstances shocks their families for several weeks, leaving them in denial. The loss of a family member, as well as hospital costs and post-mortgage expenses, especially for coronavirus patients, were among the issues mentioned in this case.
“On the first day of the new year, my husband called from the hospital and told me to take the kids 
there so that he could see them, he was feeling very well. The next day, they called from the hospital and said that my husband had died. I was very shocked. I don’t even know what really happened.”

B.4. Reducing the motivation for life
According to the interviews, after the death of family members due to COVID-19, the participants experienced grief, impatience in doing things, diminished morale, and reduced motivation to continue living.
“It’s difficult. What should I say? It’s just difficult, alright! I was the kind of kid who had the most memories with their mom. She lived with me. Wherever I look in my home, I feel her absence. She’s gone and life is never going to be the same again. It’s pointless. The grief we’re left with is unforgettable.”

C. Dissatisfaction with services
C.1. Lack of professional principles in the announcement of death
Attending to their patients in the hospital is one of the duties that all families consider themselves responsible for. A family member should be present with the patient to help meet their material demands. However, unfortunately, in the time of a pandemic such as COVID-19, such presence in hospitals is not a possibility. The hospital personnel’s disregard for people’s concerns regarding the loss of a family member, as well as the families’ dissatisfaction with the ways they were informed were among some of the issues referred to by the participants.
“They called and said that our patient had died. Just like that. The day before, they said his blood oxygen had risen and his chances of recovery had increased. Suddenly, they called and said he was dead. Easy. Just like that!”

C.2. Lack of equipment and non-compliance with hygiene standards
Failure to properly address the patients’ demands, neglecting the time of giving patients their medicine, lack of masks, not feeding the patients with liquids and food (brought by family members) on time (even though the COVID-19 patients have to drink plenty of fluids and consume food regularly), and substituting serum for food were among the issues mentioned in this section.
“My daughter said that if she was given the right clothes, she would go to the hospital and take care of her father, but not only did they not dress her, but they didn’t allow her to go to the hospital and help her father. I know everything is in God’s hands, but if they had taken better care, if they had given him hot liquids from the first day, if they had fed him some soup, he would have been cured. He was fine for the first three or four days. After that, his condition gradually deteriorated and the infection took over his lungs entirely.”
« I mean, how on earth, really? We took the patient to the hospital and admitted him, and they were painting the hospital. The smell of chemicals and paint was everywhere, bothering all the patients. Everyone in the hospital was coughing. What for? Isn’t there some other time to paint the hospital? Can’t you do the painting on any other day? Do you have to do it now? With all these Coronavirus patients, is this really the time to paint the hospital?
The daughter of one of the Corona victims who was hospitalized due to a disease other than COVID-19, stated
“The nurse who was taking care of my mother picked up the mask and put it back again on my mother’s face when the mask fell on the ground. The tube, which is attached to the patient’s nose to help with the breathing was rubbed on the bed many times and became infected, but they put it back in my mother’s nose. I called the nurse and told him he had to disinfect it or use a new device. Why did they use the contaminated equipment again?”

Discussion
The present study examined grief-related experiences in people who had lost a loved one due to COVID-19. Based on the evaluated findings, three major components were extracted, i.e. unexpressed bereavement, the effects of COVID-19 on mental health, and discontent with hospital services. Subsequently, for each main component, several sub-categories were found, each of which has been explained below in detail.
Unexpressed bereavement included three subclasses; namely, lack of farewell opportunity, the emotional burden of COVID-19, and strange burial. Anyone would react to losing someone they are  close to and would be psychologically affected by it (15). Findings of this study imply that not having adequate time to say goodbye to the deceased made it more difficult for most of the study population to believe the person’s death. Under normal circumstances, it is customary in north-east of Iran to have the body of the deceased taken to his/her own home so that the family and relatives can see deceased one last time. Then, the funeral and burial are conducted in presence of the relatives to provide the relatives with the chance to bid farewell to the deceased.
As it is already proven by some studies, it seems rational that having a good farewell can help one in coping with loss (15,16). 
Although, according to the protocols in Iran and most other countries, touching, kissing, embracing and sometimes even seeing dead bodies before the funerals were banned, and the individuals were not even allowed to hold a funeral. The fact remains that visiting a patient, holding a funeral and a mourning ceremony can be effective in facilitating the grieving process, helping faster recovery, accepting the death of a loved one, and helping the living family and relatives to start over (17-19).
Another identified subclass of unexpressed bereavement is the emotional burden of COVID-19. According to the findings of the present study, the participants reported emotions such as anger, remorse or guilt. 
This study’s findings imply that due to the social distancing policies, if a person was hospitalized, the relatives could not visit and be with him/her in the final moments of his/her death. Furthermore, due to social distancing, the bereaved could not hold a funeral for the gone member of their family, hence experiencing anger and a guilty conscience. Anger is another natural part of grief that should be solved appropriately (20). The majority of the participants declared that in case they had been with their patients, they would have done something helpful for them, or if they had taken care of them at home, the patients could have got better. Such words are indicative of the tendency of the bereaved to seek recourse to bargaining as a defense mechanism. However, if such negative self-talks continue, they will prevent the person from  accepting their loss (21).
Strange burial is another subclass of unexpressed bereavement. In our culture, holding a glorious funeral in which a great many number of relatives are present is highly important in honoring the dead and offering sympathy to the bereaved family (7).
In north-east of Iran, it is customary for the relatives and the friends to provide better companionship and support for the bereaved family on the first, the second, the seventh and the fortieth days after the death of their loved ones.  
The support, solidarity and sympathy received from those around you during the mourning ceremony are so important that can help people to go through mourning stages and reduce sadness and depression. However, in the current situation, all these psychological and social supports are taken away from the bereaved families and they find themselves alone. 
Another extracted category in this study was the effect of COVID-19 on mental health. This class includes four sub-categories, including fear and social stigma, lack of adequate psychological support, emotional trauma and shock, and decline in the motivation for life.
One of the negative impacts of this disease on mental health of the people in the society is the psychological effects of mourning loved ones as wells as anxieties and concerns about being infected and its possible consequences. Therefore, fear and social stigma are important issues within this category. Infected individuals consider themselves as a part of the disease transmission cycle, as a result of which they end up feeling fear, guilt, self-blame, and even contemplating suicide (22,23).
When people are informed of somebody’s death from COVID-19, they avoid meeting the family of that person. This can lead to prolonged feelings of sadness and depression. Moreover, the mass media frequently publishes messages about the pandemic-related mortality rate and the high risk of infection, thus spreading fear in the society (24), the mismatch of which with the officially announced records increases concerns among the public (25). Therefore, paying attention to and correctly controlling the information announced through the mass media, informing people about reliable sources of information, and not paying attention to rumors can be considered as effective steps to reduce fear and anxiety. However, taking effective actions in dealing with such unspoken grief may be possible by making telephone calls to the family and relatives of the deceased to express sympathy. Adequate psychological support reduces and heals the grief that has befallen them.
In these times of the pandemic, one who has been living healthy life can die a sudden and unexpected death shortly after being infected with COVID-19. The family of the deceased believes that a sudden death makes the situation more demanding. Studies suggest that untimely death and death in hospitals, particularly in ICU, may complicate the process of mourning. Since it is characterized by long-term and severe feeling of pain, individuals find it difficult to recover and resume their normal life (26,27).
Being shocked is the first reaction to the death of a loved one. When the family of the dead knows that the person had a medical history for a while, his/her death becomes more believable (15). As the participants in this study pointed out, facing the loss of a loved one may be a shocking experience for the bereaved family. Anyone hearing about the death of one of their family members would be devastated and would try to deny it. They do not accept it and try to make themselves believe it is not real, and it did not happen. 
Furthermore, based on the results of the conducted interviews in this study, the reduction in motivation for life among the bereaved is an important issue. Sudden death is more unbearable than the death of someone who has been ill for years. A majority of the patient’s close relatives might not even think of it for a minute. They find believing the death of that person and subsequently their own return to life very difficult, which is why psychological counselling can help them to accept the new phase of their life and to reduce their trauma.
In addition, another main component in this study was the dissatisfaction with services which itself includes two sub-categories, one of which is the lack of professional principles in the announcement of death and the other is the lack of equipment and non-compliance with hygiene standards.
Grieving families never forget when and how they were informed of the death and they remember all the details for many years. Their memories will also include the way they were informed of the death news. Empathy is very important in such circumstances. Informing someone without being careful about the principles can leave much negative and lasting effects on the family of the deceased. However, skilled the health personnel are, if they inform the family of the death news when they are not prepared for it, they are in fact interfering with the grieving process. When they are anxious or think that they cannot do it, or they are uncertain about it, in the time of delivering the news, they make themselves separated from the grieving family and thus lead the family to think that the staff only wants to do his/her job and then leave them.
According to the medical staff guidance on informing the family and giving bad news, to reduce the psychological trauma of the family of the deceased during the hospitalization, it is better to establish a therapeutic relationship with the family to increase resilience when they hear the news. It is also necessary that the person who informs the family have enough information about the patient, his/her treatment process before the death and know the patient’s name and invites the family to come to the hospital and then proceed with informing them. However, the methods suggested in this guide can differ in various circumstances considering the mental state of the family of the deceased (28,29).
Some of the individuals also reported the lack of equipment and non-compliance with health protocols during hospitalization. Due to the absence of a family member attending to the patient, hospital staff and nurses should take care of the patient’s needs, which have most of time been accompanied by the dissatisfaction of the patient’s family members. The hospitals’ standards of hygiene have a direct relationship with the prevalence of infections and diseases, the checking of which is the responsibility of the service department and the staff.
Paying attention to the environmental hygiene and the hospitalized patients is very important in improving the patients’ conditions and preventing the spread of viral disease. Moreover, those who also have underlying diseases (such as diabetes, cancer, and respiratory diseases) should be twice careful not to get infectious diseases. Non-observance of using a clean mask for the patient, the nurse’s disregard for the contamination of the patients’ useable equipment, inaccuracy of the staff in the proper use of sanitary ware were among the issues mentioned in this regard. We should make some efforts to reduce the psychological burden on the families of the deceased and to help them recover more quickly and return to their normal life. Since these people have been deprived of the customary mourning and burial ceremonies, they desperately need the necessary support and follow-up of the psychological counseling services so that they can resume their normal activities.

Conclusion
After evaluating the collected data and forming semantic units, three main categories and nine sub-categories of mourning during the COVID-19 pandemic were extracted. Unexpressed bereavement, effects of COVID-19 on health, and dissatisfaction with services made up the three main categories. According to the collected evidence concerning the mourning experience during the COVID-19 pandemic, unexpressed grief is one of the most important mental health issues during the spread of the virus.

Acknowledgements
The authors acknowledge with grateful appreciation the assistance and support provided by the North Khorasan University of Medical Sciences. The authors also would like to thank participants for their generous participation.

Conflict of Interest
The authors declare that they have no conflict of interest.

Ethics approval
The proposal for this study was approved by the Ethics Committee of North Khorasan University
of Medical Sciences. Ethics code is IR.NKUMS.REC.1399.022.