Abstract
Background: The COVID-19 pandemic has posed a major challenge for all countries. Iran is exposed to a wide range of natural and human-made hazards due to its geographical location. Therefore, preparedness is essential for a successful response to pandemics. In this study, the state of preparedness against COVID-19 in Iran was investigated.
Methods: This study is of an applied and analytical type. Qualitative data were collected using grounded theory. Semi-structured interviews were conducted with 23 individuals with a background in health management in accidents and disasters, infectious diseases, epidemiology, and passive defense. Participants were selected purposively. Qualitative data were analyzed using the continuous comparison method, and a conceptual model of national preparedness against epidemics in Iran was designed.
Results: Causal factors affecting preparedness were prerequisites, leadership, planning system, and promoters. Resilience, health system infrastructure, political situation, local situation, and nature of the disease were categorized as essential factors and adaptive and maladaptive strategies were categorized into action/interaction strategies. Consequences included social empathy, improved infrastructure, community dissatisfaction, increased psychosocial harms, reduced health system credibility, and environmental consequences.
Conclusion: The resulting framework showed that for preparedness, laws and structures need to be reformed and long-term planning should be carried out with a community-based, all-hazards and One Health approach. Information and communication management should be improved to promote community participation. Strengthening surveillance systems, establishing a single chain of command, using expert ideas and improving resilience are essential. In addition, it is possible to provide an appropriate response to future pandemics by preventing arbitrary and unscientific measures.
Keywords: COVID-19, Disasters, Empathy, Government, Grounded theory, Iran, Pandemics

Introduction
Disasters that cause ecological disorders, loss of human life, damage and deterioration of health, and require emergency response and provision of health services are considered health emergencies (1). The most important health emergencies are natural disasters and man-made accidents. Biological emergencies, epidemic threats, and severe epidemics are inherently catastrophic; Pandemics can have a more profound effect on the nature of the response in many countries (2). Preparedness against infectious diseases with an epidemic potential is a health priority and the focus of the work of the World Health Organization (WHO) (3).
Since 2019, COVID-19 treated public health worldwide and was added to the list of infectious diseases of previous epidemics (4). The outbreak of the 2019 coronavirus has challenged the existing health systems and national preparedness strategies regarding the spread of epidemic diseases around the world (5). In addition to the loss of life, epidemics cause numerous economic, social, and political losses at the regional, national, and international levels (6). 
Preparedness is one of the important parts of reducing the risk of disasters and includes measures that are taken preventively to provide an effective response in the form of comprehensive planning (7). This preparedness should adequately deal with all kinds of emergencies and disasters (8). For the United Nations and WHO, preparedness is the ability (knowledge of organizational capacity and systems) of governments, specialist responsible organizations, communities, and individuals to anticipate, identify and effectively respond to and recover from potential, impending, or existing emergencies. That is, preparedness creates mechanisms that allow national authorities, multilateral organizations, and relief organizations to be aware of risks and quickly deploy staff and resources in crises (9). 
The first international health regulations were published in 1969 to prevent, protect, control, and respond to the global spread of diseases. These international health regulations required states to notify each other of the existence of some specific diseases in their territory and to implement standard and appropriate measures to control the entry of disease into their borders (2).
In the revised version of these regulations, the responsibility of countries and the leadership role of the WHO with a systematic view of the care system, warning and rapid response systems, and vaccine production were specified, and technical cooperation and logistical support were promoted. Moreover, the way to facilitate the communication (10) between countries and sharing of services was defined and several suggestions were made for the management of epidemics (11). The WHO emphasizes that when an epidemic begins, it is too late to take the necessary measures to reduce its effects. Therefore, planning for preparation and deployment should be started before the start of the epidemic (12).
In 2020, the WHO developed a strategic program, following the COVID-19 outbreak, to prepare and respond to the epidemic in the Eastern Mediterranean region (13). In this plan, the main measures include participation and coordination, control of entry borders, international regulations and clinical guidelines, epidemiology and health information management, isolation and management of identified cases, infection control and prevention, rapid response teams, laboratory diagnostics, risk communication and interaction with the community (14), support and operation preparedness, program management and resource mobilization. Further, regional support and supporting other countries, and sharing experiences and resources are emphasized (15). The public health system and supporting procedures, programs, and functions should be adaptable for confronting the constantly evolving challenges. Continuous review of current information and implementation of public health practices and providing up-to-date instructions to public health organizations will facilitate the improvement of emergency preparedness and response planning (16). 
Several studies, including the review of the preparedness programs of European countries and the member countries of the Eastern Mediterranean region, and the comparison of Iran’s policies and strategies with the experiences of China and the WHO show that the countries of the world are not still preparing to deal with epidemic, especially emerging diseases (17-19). 
Since it is very important to know the state of the country to prepare against epidemics, in this study, the state of preparedness of Iran against covid-19 was investigated.

Materials and Methods
Study design
The present qualitative study was conducted after a review of the studies, through in-depth face-to-face interviews and the use of the grounded theory to discover the experiences of specialists and experts and finally to design a model of preparedness against COVID-19. Purposive sampling was used to select the interviewees. 

Participants
The participants were policymakers, managers, and experts of health from the Ministry of Health and universities of medical sciences, and other organizations who have experience or theoretical knowledge in the field of crisis management. The criterion for entering the study was to have experience during COVID-19. The interview continued until data saturation. Table 1 shows the data of the participants.

Data collection
A semi-structured interview was used to collect the data. First, the interviewees were asked to express their recent experiences regarding the state of preparedness against COVID-19. Then, based on their answers, other questions such as: “What factors affect preparedness?” or “What actions and reactions are taken by policymakers and executives?” and other related questions were asked. Probing questions were also used to deeply understand people’s experiences.
To collect the data, devices such as audio recorders were used. The interviewer, after informing the objects of the interview, conducted the interviews face-to-face and individually. The trust and consent of the participants to participate in this research were gained before interviewing. 

Data analysis
In this study, data collection and analysis were done simultaneously. After each interview, the audio recordings were implemented in Microsoft Word 2016. Then, following the grounded theory (Corbin and Strauss, 2015), a constant comparative analysis was performed based on three stages of open coding for primary data analysis, axial coding for classifying the extracted content, and finally selective coding for explaining the research theory. During the open coding, the research group focused on constructing the concepts. For this purpose, after studying the interviews frequently, the concepts of the extracted data were identified. Then, the extracted codes were placed in categories based on differences or similarities. The initial categories were then merged using constant comparisons to form new categories. In axial coding, the primary codes were compared to find relationships between the categories and subcategories based on their similarities and differences. Then the related groups were placed in a cluster. Finally, the main categories were formed based on their conceptual relationship with each other. Concepts and categories based on the Strauss-Corbin paradigm model were placed in 5 categories of the main topic, causal and contextual factors, strategies, and consequences.

Trustworthiness
The authors tried to analyze the content of the findings of this study with the utmost honesty and trustworthiness and present the correct picture of the objectives of the study. Credibility, transferability, verifiability, integration, and reflectivity strategies were used to obtain valid and reliable data. Constant comparison, active listening, prolonged engagement with data, data immersion, and triangulation methods were employed for validation. The experiences and work experiences of the research team in the Ministry of Health, as well as their responsibilities during the COVID-19, were also effective in obtaining the credibility of the data. To ensure the confirmability of the study findings and also to improve the transferability of the findings, member review, peer review, and expert review techniques were used. In this research, the research team tried to describe the reflective notes for the interview and the content of the interviews while recording and taking notes.

Results
In this study, 23 interviews were conducted with experts, including policymakers in the Ministry of Health and other organizations, experts in the fields of health management in crisis and disasters, health care service management, and infectious disease specialists. The interviews were conducted for 7 months from December 2022 to September 2023 and the time of the interviews lasted from 30 to 90 (on average 60) min. In the first stage of the data analysis, 1392 open codes were extracted, which were reduced to 652 codes in the next stages by continuing the process of comparison, analysis, and integration of similar cases and removing the duplicate codes or unrelated codes to the research question.
The merging of these codes formed 36. By putting together and merging similar subcategories (based on dimensions and characteristics), 10 categories were formed and finally, 5 main themes including the status of national preparedness against COVID-19 as the main problem, causal factors, background factors, strategies, and outcomes were obtained as shown in Tables 2, 3 and 4.
The findings of this study demonstrated the lack of national preparedness against COVID-19. Although some participants mentioned that preparedness exists to some extent, however, it was found that the country as a whole is not ready for such epidemics.
As shown in Table 3, causal factors as factors affecting preparedness include 4 subcategories of prerequisites, leadership, planning system, and promoters 
Contextual factors are the basis of national preparedness which are divided into two categories of endogenous and exogenous, as shown in Table 3.
Strategies are measures that are taken to solve the main problem, which includes compatible and non-compatible measures. Finally, the consequnces as the final main theme represent the results of the measures, which include two categories of positive and negative outcomes.

Table 1. Demographic data of the participants in the present study

Table 2. Open coding

Table 3. Axial coding

Table 4. Selective coding

Discussion
Grounded theory analysis led to the design of a preparedness status against COVID-19 in Iran. Causal factors included: prerequisites, leadership, the planning system, and promoters. The contextual factors as a preparedness base included 5 subcategories of resilience, health system infrastructure, political situation, local situation, and the nature of the disease. The action/interaction strategies included two compatible and non-compatible categories. The aligned category consisted of community-oriented participation, localization of knowledge and technology, and use of experts and experience-oriented measures. The non-compatible category included subcategories of measures without evidence, conflicting measures, and inequality distribution of resources. Finally, the outcomes included the subcategories of social empathy, infrastructure improvement, community dissatisfaction, increasing psycho-physical traumas, reducing the credibility of the health system, and environmental outcomes.
The law in the country and their performance bond were emphasized by the interviewees as one of the effective factors for preparing (14). Unfortunately, at the time of the official announcement of the outbreak of the disease in Iran, the National Headquarters for the fight against Corona was formed without paying attention to the existing laws and structures (20). This was observed despite the law of the country’s crisis management organization, the international IHR regulations that the country is committed to implementing, the programs of the country’s passive defense organization, and numerous related guidelines. This finding is in line with the studies of Zodpei (21) regarding the need for a law for national emergencies and its amendment and legal protection, the need for extended powers at the highest levels of government for decision-making and planning, the existence of a strong national institution, considering the epidemic as a matter of national security and the formation of a national health protection committee with the membership of all health authorities and the common understanding of leaders, policymakers and scientists (21,22). 
In this study, it was emphasized that the surveillance systems, including the early warning system and the syndromic care system in Iran, need to be strongly strengthened to be able to adapt to conditions such as emerging diseases. Accordingly, it is one of the promoters in the casual factors affecting preparedness included in the model. The rapid outbreak of the COVID-19 disease has shown that woefully local, national, and international warning systems for epidemic diseases are underdeveloped. This study is consistent with Fernley’s (13,23) which focused on the successful experience of reducing the risk of COVID-19 in countries that used the experience of Ebola, MERS, and SARS epidemics and used early warning systems based on the Sendai (24)
In their study, Baru (25), and Scales (26) stated that China and Taiwan had a significant influence on the centralized command system in the effective mobilization of government budgets, military personnel, and medical resources for disease control measures (27). Further, the findings of this study demonstrated that the chain of command is one of the most important factors in preparing for crises. Daskalo emphasized in his study that sociocultural factors affect the management and control of COVID-19 (28). Both Wang and Wang (29) pointed out in their study that the traditional culture to follow social rules and observe moral standards led people to help the government to prepare and respond to the COVID-19 pandemic and actively and spontaneously join the emergency management against the pandemic (30). These findings are in line with the model designed in this research since the interviewees considered the role of cultural factors to be very effective in preparedness. Iranians have been subject to certain cultures and customs for a long time, many of which are important factors in the spread of the virus. 
Resilience, from the perspective of the health system and society, is another important background factor that plays an important role in preparing for crises and epidemics, however, it has been neglected in the country. Paying attention to the dimensions that increase resilience is an issue that must be considered in the preparation program. The flexibility of equipment supply policies, supply chain, and service integration fundamentally increase the resilience of the health system. Maziar (31) suggested that the resilience of society is rooted in the level of education, culture, trust, and confidence in the government (32). The other most important background factor according to the interviewees was the infrastructure of the country’s health system during the COVID-19 epidemic. In the early months of the disease outbreak in Iran, there was very little medical equipment, especially ventilators, oxygen generators, negative isolation rooms, laboratory kits, prepared treatment centers, and personal protective equipment.
Wang stated that although WHO required all member states to strengthen core capacities to respond to public health emergencies under the International Health Regulations (2005), the measures of most countries to fight the COVID-19 outbreak show that they are not well prepared (30)
The political situation and the way the government and the people interact and how to be responsive, transparent, and accepting criticism affect the formation of preparation in this study. Studies also reveal that the leading countries against the COVID-19 epidemic have been more prepared and given a more appropriate response (32). 
The negative environmental outcomes caused by COVID-19 are also a factor that is emphasized in Iran and is consistent with the study of Mansour (33). Of course, some believe that Covid-19 has had positive effects due to the decrease in travel, noise pollution, and greenhouse gases (34), and this was not mentioned by the participants in the current study.
Along with all the negative effects and outcomes of COVID-19, this disease created empathy between different sections of society. Social mobilization to help needy and vulnerable patients, empathy with the medical staff and material and spiritual support to them, donations from donors to hospitals to provide medical equipment, providing personal protective equipment and sewing masks and clothes, creating virtual groups for creating positive energy and enduring the quarantine period are examples that we have not witnessed before the COVID-19 disease. Research confirms the importance of empathy to deal with the spread of the virus and at the same time preventing economic collapse (35).

Conclusion 
The COVID-19 epidemic is a cross-border crisis that requires different programs with a base of requirements to prepare for it in different countries with different background conditions, therefore, a comprehensive and national preparedness plan in the countries is essential.
Reforming the existing structures in the country and preparedness laws against biological and natural crises, strengthening the information (36), health and non-health infrastructures are necessary to be reviewed and given serious attention. A planning system with a comprehensive approach, all risks, government, all society, One Health approach, close cooperation with crisis management and health management, and understanding the epidemic as a crisis form the basis for the preparedness plan. These requirements should be developed according to the existing context including the local situation, political situation, infrastructure of the health system, and resilience.
Considering the local conditions and the vast differences in cultural, social, and economic conditions of the society, the political situation of the country, and the existence of sanctions, the preparation in the country requires extensive inter-sectoral cooperation and coordination within the country and trans-sectoral with other countries. Learning from past experiences, global cooperation, and the creation of strong supply chain networks for the equitable distribution of resources in the required areas, the importance of long-term budgeting to support public health preparedness in critical situations, and promoting resilience are other requirements that should be given serious attention.

Acknowledgement 
This study was part of a doctoral thesis at the Islamic Azad University, North Tehran branch, which was approved by the code of ethics of IR.IAU.TNB.REC.1400.038.

Conflict of Interest
There are no conflicts of interest.