Coping With Bereavement and Loss Experiences Among Families of Deceased due to COVID‐19 in Guilan Province, Northern Iran: A Cross‐Sectional Study

ABSTRACT

Background and Aims

The loss of a loved one due to COVID‐19 can result in significant psychological distress and maladaptive coping responses. This study aimed to investigate the coping with bereavement and loss experiences and related factors among families of individuals deceased due to COVID‐19.

Methods

This cross‐sectional study was conducted among 220 residents of Guilan Province, northern Iran, who had experienced the loss of a family member (father, mother, spouse, child, sister, or brother) due to COVID‐19 within the past 6 months. Participants were selected using simple random sampling and completed a demographic survey and the Coping Assessment for Bereavement and Loss Experiences (CABLE) questionnaire. Data were analyzed using descriptive and inferential statistics with SPSS software version 21.

Results

The mean score for coping with bereavement and loss experiences was 84.17 ± 19.75. Significant relationships were found between coping with bereavement and the demographic characteristics of age (F = 3.091, p < 0.05, η² = 0.732) and job type (F = 2.914, p < 0.05, η² = 0.778). No significant relationships were observed with other demographic variables (p > 0.05). Multiple regression analysis indicated that age was the only significant predictor of coping with bereavement and loss experiences, with a standardized coefficient (β) of 0.423, t = 2.149, p < 0.05.

Conclusion

This study provides insights into the bereavement experiences of families who lost loved ones to COVID‐19. It highlights the importance of considering demographic characteristics when providing support to these families. The findings can inform targeted interventions to improve mental health outcomes and well‐being among bereaved families.

Summary

• The COVID‐19 pandemic has resulted in widespread loss of life, leading to significant psychological distress and maladaptive coping responses among families who have lost loved ones.

• Sudden and unexpected deaths, such as those caused by COVID‐19, can trigger complex and prolonged grief reactions.

• Families who have experienced loss due to COVID‐19 are particularly vulnerable to adverse psychological outcomes.

• This study highlights the importance of considering demographic characteristics, particularly age and job type, in understanding the coping mechanisms of bereaved families.

• Notably, this study identifies age as a significant predictor of coping with bereavement and loss experiences, emphasizing the need for targeted interventions and support for older adults who have lost loved ones due to COVID‐19.

1. Introduction

The novel coronavirus (SARS‐CoV‐2), which causes the disease known as COVID‐19, was first identified in Wuhan, China, on December 30, 2019 [1]. The rapid spread of the virus within the country led to a significant public health crisis, prompting the World Health Organization (WHO) to declare it a global health emergency later that year [2]. Despite the widespread dissemination of health advisories and preventive measures, few individuals around the world have remained unaffected by the disruptions and personal losses brought about by this dangerous disease. However, the public situation of those who have lost a family member to this disease has been underreported by many media outlets [3].

Death is an inevitable reality, and each person may have a unique reaction to it [4]. The loss of a loved one is typically a profound and emotionally challenging experience [5]. Mourning, the psychological process following a significant loss, encompasses a range of emotions and reactions triggered by the death of a loved one [6]. The impact of such a loss often extends beyond the immediate emotional response, affecting various aspects of an individual's life [7]. Grief, a multifaceted response to the loss of a loved one, can manifest in a variety of complex and sometimes contradictory emotions [8]. Individual responses to grief can vary widely, influenced by how one adapts and copes with the loss [9]. Factors such as sociodemographic, physical, psychological, and social factors influence the ongoing adjustment to grief [10, 11].

Understanding the concept of grief is both difficult and complex, given the individual and cultural differences across societies [11, 12]. Traditionally, early mourning is considered a normal response that occurs immediately after the death of a loved one [13]. However, in cases of unexpected deaths, such as those due to the COVID‐19 pandemic, traditional mourning rituals and physical social support are often absent [14]. In Iran, for example, the mourning culture is characterized by mass funerals and extensive ceremonies attended by friends and acquaintances. In some cases, close friends or relatives stay with the bereaved for up to 7 days, providing essential emotional and practical support [15].

During the COVID‐19 pandemic, families who lost loved ones faced unprecedented psychological challenges. They were often unable to attend funerals or perform burial ceremonies, leading to a new and isolating experience of grief [16]. The absence of traditional rituals and social support structures has been a significant factor in the bereaved's ability to cope with their grief [17]. The bereaved family members were under immense stress, and the lack of support from colleagues, friends, and family exacerbated the complexity of their grief [18]. In these circumstances, there is also the possibility of prolonged grief disorder [19].

During this pandemic, there have been limited studies on grief experiences in families of those who have lost loved ones to COVID‐19 [16, 17, 18, 19, 20], and more studies are needed due to the complex nature of grief adjustment and sociocultural differences. In particular, the role of related factors in coping with grief has received less attention in studies. Therefore, the present study aimed to investigate the coping with bereavement and loss experiences and related factors among families of individuals deceased due to COVID‐19.

2. Method

2.1. Study Design, Setting, and Participants

This cross‐sectional study was conducted in the eastern cities of Guilan Province, located in northern Iran, from September 2021 to March 2022. A total of 220 participants were recruited who had experienced the loss of a loved one due to COVID‐19 and met the predetermined inclusion criteria. The inclusion criteria consisted of having lost a family member (father, mother, spouse, child, sister, or brother) to COVID‐19 within the past 6 months, not having any communication difficulties, and being able to understand and communicate effectively.

A simple random sampling technique was employed to select participants for this cross‐sectional study. The sampling frame consisted of a comprehensive list of patients who had been hospitalized and deceased due to COVID‐19, compiled from hospital records during the study period. To ensure a representative sample, the following steps were taken:

(1) A comprehensive list of deceased patients and their family members' contact information was compiled from hospital records. (2) A random sample of 220 family members was selected from the list using a computer‐generated random number generator, ensuring every family member had an equal chance of being selected. (3) Family members who refused to participate or were unable to understand and communicate effectively were excluded from the study. (4) The selected participants' eligibility was verified based on the inclusion and exclusion criteria, with only those who had lost a family member within the past 6 months being included in the study.

The simple random sampling technique was chosen to minimize bias and ensure a representative sample. This approach increased the generalizability of the study findings to the broader population of family members who have lost a loved one due to COVID‐19.

For sampling, the researcher contacted these individuals by phone, explained the study objectives to them, and, if they were willing to participate in the study, arranged to meet them at a designated time and place. During a face‐to‐face meeting with them, the questionnaires were provided to them so that they could complete them if they agreed.

2.2. Research Instruments

The research instruments included demographic characteristics (age, sex, marital status, place of residence, level of education, job, and monthly income) and a questionnaire on coping assessment for bereavement and loss experiences, which is explained below.

2.3. Coping Assessment for Bereavement and Loss Experiences (CABLE)

This questionnaire was designed and psychometrically evaluated by Crunk et al. in 2019 [21]. This tool is used to identify the strategies that bereaved people use to cope with their grief. The initial version included 89 items, which were reduced to 28 questions and 6 domains: Help‐Seeking (7 items), Positive Outlook (5 items), Spiritual Support (4 items), Continuing Bonds (5 items), Compassionate Outreach (3 items), and Social Support (4 items) [11]. Help‐seeking measures the extent to which individuals seek external assistance or support in coping with their grief. A positive outlook reflects the individual's tendency to maintain an optimistic or hopeful perspective during the mourning process. Spiritual support assesses the role of spiritual beliefs and practices in coping with loss. Continuing bonds measure the ongoing emotional connection the individual maintains with the deceased. Compassionate outreach evaluates the extent to which the individual engages in acts of kindness or support toward others during their grieving. Finally, Social support reflects the individual's reliance on and perception of social networks for emotional and practical support.

The questionnaire items are scored on a 5‐point Likert scale ranging from 0 (never) to 4 (always). There is also an option (N/A) that means “not applicable”. The obtained scores are reported as the mean score. The higher the score, the more coping strategies an individual is using in this area [22].

The reliability of this questionnaire in Crunk et al.'s study (2019) through Cronbach's alpha was 0.95 [21], and in the study by Qasim and Carson was 0.89 [23]. The psychometric properties of this tool were evaluated in Iran by Ebadi et al. Cronbach's alpha for all items was 0.91, and the intraclass correlation coefficient (ICC) was 0.86. These values indicate high internal consistency and test‐retest reliability, respectively, confirming the reliability of the tool [11].

To use this questionnaire, after obtaining permission from the researcher who designed the instrument, the questionnaire was first translated into Persian based on the forward‐backward method. First, the questionnaire was translated into Persian by two translators fluent in English who worked in the field of medical texts, and an initial Persian version was prepared. The translated version of the questionnaire was subsequently translated into English by two other people independently. Then, the researchers and translators compared the original version and its translation with each other and made minor edits to the questionnaire. To ensure content validity (CVR: content validity ratio; CVI: content validity index), this questionnaire was administered to 10 faculty members of the Nursing and Midwifery Faculty of Guilan University of Medical Sciences, and they were asked to express their opinions about the “necessity,” “relevancy,” “similarity” and “clarity” of the questionnaire statements. A CVI of 0.84 and a CVR of 0.79 were calculated. The reliability of the questionnaire in the present study was calculated using Cronbach's alpha coefficient (0.84).

2.4. Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 21 (IBM Corp., Armonk, NY, USA). Descriptive statistics (mean, standard deviation, frequency, and percentage) were used to summarize demographic data. Inferential statistics included the following: t‐tests for comparing two independent groups. Analysis of Variance (ANOVA) for comparing more than two groups. Linear regression for examining relationships between variables.

Effect size was calculated using Cohen's d for comparisons between two groups and eta squared (η²) for comparisons between more than two groups. Normality of the data was assessed using the Kolmogorov–Smirnov test. A significance level of p < 0.05 was applied for all statistical tests.

2.5. Ethical Considerations

This study was approved by the ethics committee of Guilan University of Medical Sciences (ethics ID IR.GUMS.REC.1400.242, approval date: September 1, 2021) in Iran. The study was performed under the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from all participants included in the study.

3. Results

3.1. Demographic Characteristics of the Family of the Deceased due to COVID‐19

The majority of the participants were between 36 and 59 years old (62.6%), female (69.4%), married (75.7%), academically educated (55.2%), or employed (37.9%). Most of the respondents were urban residents (81.9%) with a middle economic status (56.2%).

3.2. Determining the Mean Score for Coping With Bereavement and Loss of Experience in the Family of the Deceased due to Corona Disease

The mean total score for coping with bereavement and loss experienced by the families of the deceased due to COVID‐19 was 84.17 ± 19.75 (Table 1).

Table 1.

Mean scores for coping with bereavement and loss experiences in the families of the deceased due to COVID‐19 (n = 220).

Dimensions of coping with bereavement and loss experiences	Mean	SD	Min	Max
Help‐seeking	19.01	6.09	9	35
Positive outlook	15.87	3.80	6	25
Spiritual support	12.37	4.12	5	20
Continuing bonds	16.67	4.47	8	25
Compassionate outreach	9.10	3.29	3	15
Social support	11.13	3.80	4	20
Total coping	84.17	19.75	43	140

3.3. Relationship Between Demographic Characteristics and Coping With Bereavement and Loss Experiences

The results showed that the highest mean scores for coping with bereavement and loss experiences were obtained for individuals aged ≥ 60 years (101.70 ± 28.40), females (85.62 ± 20.37), married individuals (86.58 ± 21.05), village residents (88.05 ± 19.46), farmers (100.12 ± 23.03), those with sufficient income (89.18 ± 22.07), and those with a primary/high school education level (92.00 ± 27.30) (Table 2).

Table 2.

Relationship between demographic characteristics and coping with bereavement and loss experiences among the family of the deceased due to COVID‐19 (n = 220).

Variables		n (%)	Dimensions of coping with bereavement and loss (mean ± SD)							Min	Max	Tests	p value	Effect sizea
			Help‐seeking	Positive outlook	Spiritual support	Continuing bonds	Compassionate outreach	Social support	Total
Age (year)	≤ 20	6 (2.6)	17.33 ± 4.13	12.33± 0.51	7.67 ± 2.06	17.00 ± 1.54	12.67 ± 2.06	12.67 ± 1.03	79.66 ± 9.23	69	85	F = 3.091	p = 0.030	Eta squared = 0.732
	21–35	54 (23.8)	18.48 ± 4.948	15.19 ± 3.15	12.30 ± 4.89	16.15 ± 3.87	8.63 ± 2.83	11.04 ± 2.91	81.77 ± 14.78	60	101
	36–59	140 (62.6)	18.80 ± 6.25	15.83 ± 3.94	12.29 ± 3.65	16.46 ± 4.52	8.84 ± 3.18	10.57 ± 3.62	82.78 ± 28.40	43	140
	≥ 60	20 (11.0)	22.50 ± 7.24	19.10 ± 2.95	14.60 ± 4.10	19.50 ± 5.29	11.10 ± 4.14	14.90 ± 5.28	101.70 ± 28.40	61	131
Sex	Female	150 (69.4)	18.80 ± 6.39	16.41 ± 3.83	12.83 ± 3.86	16.93 ± 4.52	9.05 ± 3.32	11.60 ± 3.88	85.62 ± 20.37	49	140	t = 1.131	p = 0.260	Cohen's d = 0.232
	Male	70 (30.6)	19.49 ± 5.36	14.71 ± 3.47	11.40 ± 4.47	16.11 ± 4.31	9.20 ± 3.22	10.14 ± 3.39	81.05 ± 18.24	43	120
Marital status	Single	38 (15.7)	17.05 ± 4.38	13.95 ± 3.27	9.63 ± 2.81	16.00 ± 3.46	9.84 ± 2.69	10.21 ± 3.21	76.68 ± 15.05	49	102	F = 2.381	p = 0.097	Eta squared = 0.531
	Married	162 (75.7)	19.78 ± 6.34	16.10 ± 3.91	13.09 ± 4.24	16.62 ± 4.72	9.25 ± 3.22	11.75 ± 3.87	86.58 ± 21.05	43	140
	Divorced/widowed	20 (8.5)	16.60 ± 5.37	17.70 ± 2.05	11.80 ± 2.62	18.40 ± 3.67	6.50 ± 3.64	7.90 ± 1.48	78.90 ± 11.48	64	98
Place of living	City	182 (81.9)	18.71 ± 6.19	16.12 ± 3.83	12.15 ± 4.03	16.46 ± 4.49	9.01 ± 3.34	10.90 ± 3.72	83.36 ± 18.82	43	140	t = −0.941	p = 0.349	Cohen's d = −0.237
	Village	38 (18.1)	20.47 ± 5.35	14.68 ± 3.41	13.42 ± 4.37	17.68 ± 4.27	9.53 ± 2.94	12.26 ± 3.94	88.05 ± 19.46	63	131
Education	Illiterate	6 (2.6)	20.00 ± 4.09	15.67 ± 1.86	13.00 ± 3.22	15.67 ± 4.50	7.67 ± 0.51	9.33 ± 2.25	81.33 ± 15.56	65	96	F = 1.915	p = 0.132	Eta squared = 0.635
	Primary/high school	20 (9.9)	20.80 ± 7.26	17.00 ± 3.11	12.50 ± 5.07	17.90 ± 4.93	10.10 ± 3.16	13.70 ± 4.33	92.00 ± 27.30	61	131
	Diploma	76 (32.2)	17.66 ± 6.21	14.82 ± 3.70	12.05 ± 3.44	15.76 ± 4.51	8.50 ± 3.27	9.76 ± 3.93	78.55 ± 18.51	43	120
	Academic	118 (55.2)	19.54 ± 5.75	16.37 ± 3.91	12.53 ± 4.39	17.10 ± 4.29	9.39 ± 3.32	11.68 ± 3.30	86.61 ± 18.79	51	140
Job	Employee	80 (37.9)	20.45 ± 6.26	16.75 ± 4.43	12.65 ± 4.09	17.15 ± 4.60	9.10 ± 3.57	11.52 ± 3.69	87.62 ± 21.19	43	140	F = 2.914	p = 0.012	Eta squared = 0.778
	Worker	16 (6.1)	15.63 ± 3.82	12.75 ± 2.81	9.75 ± 3.49	14.75 ± 3.49	8.63 ± 2.06	8.63 ± 2.72	70.12 ± 11.28	63	96
	Self‐employed	38 (15.3)	17.53 ± 4.11	15.42 ± 2.91	11.32 ± 4.10	15.58 ± 4.58	9.05 ± 2.74	10.42 ± 1.92	79.31 ± 14.15	61	102
	Retired	18 (9.1)	20.67 ± 3.59	16.44 ± 3.9	12.67 ± 3.85	18.11 ± 3.44	10.44 ± 3.07	15.22 ± 3.75	93.55 ± 18.09	64	120
	Farmer	16(8.7)	23.00 ± 9.09	16.75 ± 3.04	16.75 ± 2.86	19.38 ± 3.86	11.75 ± 2.46	12.50 ± 4.89	100.12 ± 23.03	75	131
	Housewife	32 (13.4)	16.94 ± 6.78	16.63 ± 3.30	11.56 ± 3.04	15.94 ± 5.06	7.19 ± 3.37	9.50 ± 3.19	77.75 ± 20.09	53	112
	disabled/unemployed/other	20(8.6)	17.50 ± 4.28	13.30 ± 1.45	12.90 ± 4.66	16.10 ± 3.35	9.30 ± 2.71	10.80 ± 4.32	79.90 ± 14.81	49	93
Economic status	Low	28 (13.0)	18.93 ± 4.08	15.79 ± 3.46	13.71 ± 3.25	19.21 ± 3.40	9.36 ± 3.32	9.14 ± 2.39	86.14 ± 8.90	73	102	F = 1.836	p = 0.164	Eta squared = 0.738
	Middle	128 (56.2)	18.86 ± 6.63	16.00 ± 3.99	11.16 ± 3.36	15.63 ± 4.08	8.77 ± 2.94	10.83 ± 3.46	81.23 ± 19.92	43	140
	High	64 (30.8)	19.38 ± 5.69	15.66 ± 3.58	14.22 ± 4.91	17.66 ± 4.96	9.66 ± 3.83	12.63 ± 4.37	89.18 ± 22.07	51	131

Note: SD (standard deviation), min (minimum), and max (maximum).

^a Cohen's d was used to calculate the effect size between two group means, and Eta squared was used for more than two groups.

Findings regarding the relationships between demographic variables and coping with bereavement and experiences of loss among the families of the deceased due to COVID‐19 indicated that there were significant relationships between coping with bereavement and the sample's age (F = 3.091, p < 0.05, η² = 0.732) and job type (F = 2.914, p < 0.05, η² = 0.778); however, no significant relationships were observed with other variables (p > 0.05) (Table 2).

3.4. Regression Analysis

Due to the presence of five variables (age, marital status, education level, employment status, and economic status) with p≤ 0.2 in Table 2, these variables were included in the regression model. In the final stage, the factor “age” remained the main variable significantly related to coping with bereavement and loss experiences, with a standardized coefficient (β) of 0.423, t = 2.149, p < 0.05 as shown in Table 3.

Table 3.

Results of the regression model to determine the main variable in the relationship between demographic characteristics and coping with bereavement and loss experiences among the family of the deceased due to COVID‐19 (n = 220).

Variable	B	SE	Beta	t	p value	95.0% Confidence interval for B		Collinearity statistics
						Lower bound	Upper bound	Tolerance	VIF
Constant	54.834	16.062		3.414	0.001	22.982	86.685
Education	2.393	3.022	0.093	0.792	0.430	−3.599	8.386	0.654	1.530
Marital status	0.738	4.130	0.019	0.179	0.859	−7.453	8.929	0.795	1.259
Job	−0.393	1.027	−0.043	−0.383	0.703	−2.429	1.643	0.717	1.396
Economic status	1.414	3.194	0.045	0.443	0.659	−4.920	7.748	0.872	1.146
Age	0.423	0.197	0.236	2.149	0.034	0.033	0.814	0.747	1.339

4. Discussion

In this study, coping with bereavement and experiences of loss and its relationship with related factors in the families of deceased people due to COVID‐19 were investigated. The findings of the present study showed that the mean score for coping with bereavement and loss of experience in the families of individuals who died due to COVID‐19 was 84.17 ± 19.75. In other words, these findings showed that the families of those who died due to COVID‐19 were able to adapt relatively well to the experience of bereavement and loss 6 months after the death of their loved ones. The findings of the study by Fayyazi Bordbar et al. showed that in terms of the severity of bereavement experience, the average bereavement experience among the families of the deceased was severe, which is not consistent with the findings of the present study [24]. The difference in the findings may be due to the inclusion criteria of the two studies. The inclusion criterion in the present study was that loved ones died due to COVID‐19 at least 6 months ago; however, this criterion was not met in the study by Fayyazi Bordbar et al. and all people who had lost a loved one, in general, were included in the study. According to the announcement of the American Psychiatric Association (2020), a period of 6 months is the time when adaptation should be achieved naturally (more than that is considered a prolonged state of intense grief) [25]; this criterion was met in the present study. Additionally, the results of the Lin et al. study showed that the mean score on the coping with grief subscale was the lowest among Chinese nurses [26]. This finding is not consistent with the findings of the present study. Coping with bereavement is a complex process that involves adjusting to life without the deceased person and finding new ways of living [24]. The COVID‐19 pandemic has made this process even more challenging due to the unique circumstances surrounding this loss [27].

The findings regarding the relationships between demographic characteristics and coping with bereavement and loss experiences in families of people deceased due to COVID‐19 showed that the highest mean score for coping was for older adults, which suggests that elderly people have better coping with the experiences of grief caused by COVID‐19. Additionally, the findings indicated that there is a significant relationship between age and coping with bereavement.

Several studies have shown that older people experienced fewer psychological symptoms during the COVID‐19 pandemic than younger people did [28, 29]. It was also shown that older adults are better at controlling emotions and dealing with stressful events [30, 31].

The elderly individuals in the study by Şentürk et al. were found to have high levels of adaptation [32]. The increase in adaptability in old age can be explained by the fact that elderly people have faced many issues and problems during their lives and lifespan, and they have learned how to address problems and crises such as the COVID‐19 pandemic. As mentioned in the Lind et al. study, elderly people may have found it easier to cope with these stressors by applying coping strategies learned from living through other important historical events [33]. Adaptation in old age is regarded as accepting changes such as diseases caused by aging; physical, psychological, and economic losses; and limitations imposed on one's activities, and adaptation to these issues is achieved through the development of healthy coping skills [32, 34]. Furthermore, older adults during the pandemic were more likely than younger adults to use problem‐focused and proactive coping strategies and less likely to use counterproductive coping strategies related to stressors [29, 35]. These findings collectively suggest that older adults' coping strategies, decision‐making skills, and proactive coping may contribute to their ability to cope better.

Additionally, the findings showed that the highest mean score for coping with bereavement and loss experienced by the family of a deceased person due to COVID‐19 was related to the female gender. Sex is often considered a risk factor for pathological bereavement [10]. Bereavement is a context characterized by heightened emotional intensity, and gender socialization processes play an important role in men's and women's cognitive, emotional, and behavioral responses to the death of a loved one [36]. Regarding the effect of sex on bereavement outcomes, there is no agreement in the results of scientific studies. Some conclude that widows suffer more health problems than widowers do, although most researchers say the opposite [37]. However, cultural gender differences in bereavement are common in terms of how men and women behave when grieving. Gender differences also influence the coping process of bereavement [7]. Women show greater emotional expression overall, particularly for positive emotions and internalizing negative emotions such as sadness and anxiety, but men express greater levels of aggression and anger than women in some contexts [38]. Females are considered more interpersonal and better at emotional expression than males are; they seek others for support and are encouraged to express their emotions more often than males are [36]. Nevertheless, females report more mental health problems than males [7, 39]. Males are socialized not to express their emotions and engage in more problem‐solving methods, thinking more about the loss than about the loss. Minimizing negative emotions may help males in their grief. Instead, males may exhibit behavioral outbursts more than females. More research is needed to understand gender differences in people's bereavement [7].

The findings also showed that the highest mean score for coping with grief and loss experience related to the family of the deceased due to COVID‐19 was related to married individuals. Much research refers to average differences in well‐being between bereaved and non‐bereaved individuals, which usually does not allow deeper insight into the heterogeneity of adaptation to loss [40]. While some bereaved individuals successfully adapt to new living conditions and show well‐being values equal to those of their married peers, others suffer from long‐lasting psychological problems [41, 42]. However, support from emotionally close persons can provide the psychological resources needed to cope with stress and buffer the negative effects of life stress on marital satisfaction [43]. The better adaptation of married people in the present study could be due to their spouses supporting each other in difficult life situations, which made it easier for them to bear the death of their loved ones. Spouses expect partners to “be there” to help solve problems and provide consolation when problems lack solutions. Although both husbands and wives turn to others in their social networks for various types of support, spouses remain an important source of support [43].

The findings showed that the highest mean score for coping with grief and loss experiences for the families of the deceased due to COVID‐19 was obtained in those who were farmers in terms of job status. Additionally, the findings indicated that there is a significant relationship between adaptation to bereavement and job. Working in the green environment of a village for agriculture allows these people to adapt to problems more effectively. There is extensive empirical literature on the association between exposure to nature and health [44]. Research has examined green outdoor settings as a potential treatment for mental and behavioral disorders [44, 45, 46]. The results from experimental studies provide evidence of the protective effects of exposure to natural environments on mental health outcomes and cognitive function [44]. One study by Morales et al. suggested that individuals living in rural areas are less likely than residents of urban areas to seek professional help for psychological distress [47]. In line with the findings of several previous longitudinal studies, total green space appeared to be associated with lower odds of incident psychological distress. The results of a systematic review provided evidence of the positive benefits of green space for adolescents, especially in terms of reduced stress, positive mood, fewer depressive symptoms, better emotional well‐being, improved mental health and behavior, and lower psychological distress [48]. These findings are in line with previous systematic reviews [45, 46, 49, 50, 51]. A majority of the findings showed statistically significant positive relationships between green space and mental health.

The findings showed that people who had enough income had the highest mean score for adaptation to bereavement and loss experiences. According to a review, bereavement during COVID‐19 is associated with an increased risk of mental health problems, and economic status is an important factor in bereavement [52]. A state of poverty is also known to increase the risk of psychological distress in the general population. The findings of the study by Cacciatore et al. revealed that poverty was the strongest predictor of psychological distress when compared to other factors that have traditionally been considered significant in parental bereavement. People who are living in poverty have fewer available resources and are less likely to seek support for their suffering. Individuals who are living with lower levels of household income or with lower levels of education are also at greater risk of comorbid problems, which in turn are likely to present at a more serious level than those who have higher incomes. Since people who are economically disadvantaged and who have lower levels of literacy appear to be at greater risk of developing symptoms of psychological distress following the death of their loved ones, their needs must be prioritized when services are being planned [53]. A low level of income is a factor that contributes, indirectly, to slowing down the adjustment to bereavement [10]. Financial difficulties can have an impact on social activities by limiting them or even making them nonexistent, which could increase mental ruminations relating to the loss and thus make bereavement more difficult [10, 54].

The findings showed that the individuals with the highest mean score for adaptation to bereavement and loss in family experience among the deceased due to COVID‐19 were people who had primary/high school education. This finding can be explained by the fact that people who have a higher level of education are looking for more information in different media, and the results of these many searches in different media can cause more fear and anxiety and increase the psychological effects of COVID‐19 on them, increasing the extent to which these individuals adapt to these psychological problems. Several studies have shown that people who follow news related to COVID‐19 usually experience more anxiety [55]. In addition, news and rumors can aggravate symptoms of depression in society [56]. Depression, anxiety, psychological and emotional strain, and psychological distress are associated with poor adjustment to grief [10].

The study's findings have implications for healthcare providers, policymakers, and researchers. Healthcare providers should consider the demographic characteristics of bereaved families when providing support and interventions. Policymakers should develop culturally sensitive and tailored support services for families affected by COVID‐19. Researchers should explore the effectiveness of interventions aimed at promoting coping with bereavement and loss experiences among families of deceased due to COVID‐19. Managers should invest in education related to coping strategies for bereavement support for people in the community and provide cultural interventions for coping with bereavement, focusing on forming support groups, holding workshops, and providing information through the media. With the death of loved ones due to the recent COVID‐19 pandemic, people have experienced considerable stress and sadness at different levels. Counseling and health centers, and mosques where people live may be the first places where many people turn to for support. Therefore, supportive programs, policies, and protocols must be in place to ensure that recently bereaved people are cared for so that they can adapt to grief and gradually return to their normal lives.

4.1. Limitations

Among the limitations of this study is the use of a self‐assessment questionnaire, which may be influenced by individual cognition as well as social and cultural expectations or constraints. Future research could benefit from qualitative approaches, such as long‐term, in‐depth interviews, to gain a deeper understanding of the process of adaptation to bereavement and the experiences of loss among families who have lost loved ones to COVID‐19. Additionally, interventional studies are recommended to explore the effects of various interventions on the mourning process of bereaved family members.

Another limitation of this study is its conduct within a specific cultural context, which may limit the applicability of the findings to other cultural settings. To enhance the generalizability of the results, it is recommended that the research question be replicated in different cultural contexts.

5. Conclusion

The findings of the present study showed that coping with the mourning of loss experiences in families of deceased people due to COVID‐19 was relatively effective. However, health managers and policymakers should plan to develop interventions to increase the likelihood of better adaptation in families of deceased people due to COVID‐19. The findings also showed that the participants with the highest mean scores for coping with bereavement and loss experiences were elderly people, women, married people, village residents, farmers, those with sufficient income, and those with a primary/high school education. These findings indicate that coping with bereavement is very complex and is influenced by various factors, including demographic characteristics. The results of the present study can be considered by authorities when determining appropriate strategies for better adaptation in prevention and protection programs.

Author Contributions

Azar Darvishpour: conceptualization, investigation, writing – original draft, validation, visualization, methodology, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources. Fatemeh Mansouri: investigation, conceptualization, writing – original draft, writing – review and editing, methodology, validation, visualization, resources, data curation, software. Mahdavi Fashtami: conceptualization, investigation, writing – original draft, writing – review and editing, data curation, resources, methodology, visualization, validation. Shirin Aramesh: resources, data curation, methodology, writing – review and editing, visualization, validation, conceptualization, investigation, writing – original draft. Ali Nourisaeed: methodology, validation, visualization, writing – review and editing, conceptualization, investigation, writing – original draft, data curation, resources.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Azar Darvishpour, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The data sets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.