Grief Experience After Deaths: Comparison of Covid-19 and non-Covid-19 Causes.

The grief caused by loved ones' death causes grief is a global phenomenon. The Covid-19 pandemic caused significant changes in human lifestyles and the experience of grief. The purpose of the present study was to compare grief experiences in the deceased's relatives caused by Covid-19 and non-Covid-19. Seventy-five first- and second-degree relatives of the deceased infected with Covid-19 (n = 33) and non-Covid-19 (n = 42) in a Gorgan hospital in northern Iran were included cross-sectional study using convenience sampling. Data were collected using the GEQ-34 grief experience questionnaire and demographic variables and questions related to funeral and burial. The results revealed that the deceased's burial quality caused by the Covid-19 group was significantly lower (p = 0.035). However, the feeling of the Covid-19 label is significantly higher (p <0.001). There was no significant variation in grief's broad experience between the two groups (P > 0.05). Nevertheless, the experience of grief was significantly different in the group of relatives of the deceased infected by Covid-19 in terms of notoriety (P = 0.040) and physical reactions (p = 0.002). Educational interventions to reduce stigma and discrimination due to death caused by Covid-19 and clinical and psychological support of relatives of the deceased due to Covid-19 are recommended by compiling appropriate messages from different channels.

Introduction

Grief is an unavoidable experience in everyone's life. However, the ability to accept grief extends from accepting grief to having severe outcomes (1). Grief is commonly a set of emotions, thoughts, and behaviors that people experience during loss or the threat of loss (2). Grief is different in various people, while grief is pervasive in all human societies. Moreover, various people accept the reality of loss, grief, and its consequences in various ways. In several cases, the grief period is naturally experienced by the bereaved as a fact of life. However, few cases lead to some severe psychological and physical disorders during this period (3). The process of coping with loss could affect a person's future life. Therefore, most bereaved people show relative disturbances in their performance in the first year after loss (4).

Although the continuation and severity of the response to bereavement depend on the suddenness of death and the individual's cultural characteristics, the common symptoms of grief gradually diminish and should not last more than six months in a year. However, grief's progression may be unusual in some people; therefore, the symptoms and associated behaviors may persist for a more extended period and require serious psychiatric intervention (5,6).

The prevalence of grief and its outcomes differ, considering differences in social norms and cultural expectations. Determining the stages, duration, and complexities of grief is challenging because of these individual and cultural diversities; however, the disorder's prevalence and features are different in various cultures and societies. The cause of death has perpetually been a factor in the grief response, and there is sufficient evidence that sudden death leads to a more severe reaction in survivors. Nevertheless, it is ambiguous whether there is an association between the type of death and the relativeness degree in the severity of grief reactions (7). In the era of COVID-19 due to social distancing, For bereaved individuals, funerals and burials are postponed or held remotely, often without presence of family or the possibility of the warm embrace from loved ones (8). It seems that grief becomes increasingly prolonged, complicated, or even traumatic when the normal rituals and the traditional funeral concerning death to do not take place (9,10)

The Covid-19 pandemic has turned the public image of human societies. According to WHOreporte,Globally, as of 14 January 2022, there have been 318,648,834 confirmed cases of COVID-19, including 5,518,343 deaths. In Iran (Islamic Republic of), from 3 January 2020 to 6:03pm CET, 14 January 2022, there have been 6,214,781 confirmed cases of COVID-19 with 132,002 deaths, reported to WHO (11–13).

In Iran, mourning ceremonies are different in different subcultures, but in general, after the death of a loved one, funerals and burials are held, and in this process, a large number of family members, relatives and acquaintances gather together and offer condolences to the mourners. Say. Also, on the third, seventh, fifteenth and fortieth days after loved one death, a ceremony will be held, all of which will cause emotional support to the deceased family members.

Temporary or permanent cessation of foundations and modifications in attitudes and behaviors have entirely changed civil life (14,15). The high infection rate of Covid-19 and its severe and unknown outcomes compared to common viral diseases such as influenza have made it possible for the patient's relatives to lose communication and meet directly with the patient during the disease (16). It is natural that when symptoms of relatives’ disease appear, a more obnoxious experience of the mentioned disorders will occur, (17) significantly if the patient's quarantine and hospitalization do not reduce clinical symptoms and treatment and lead to loss and death of the patient (13,18,19). These conditions intensify the experience of loss and grief in a person's relatives and loved ones to the suffering and could put them at risk of mental breakdown and behavioral disorders. Acute and rapid progression of inflammation of Covid-19, in many reports, elaborate these risks to an intolerable degree in the patient's relatives, whether therapists or relatives (20,21). Therefore, it is essential to examine the experience of grieving in people involved with the deceased caused by the infection by Covid-19 compared to people involved with non-Covid-19 deceased. The Golestan Province in situated in the north of Iran and south-east of the Caspian Sea.The Gorgan city is the capital of the province which is multi-culture and included some Iranian sub-culture in its society.Therefore, the present study was conducted to compare grief in first- and second-degree relatives of deceased infected by Covid-19 and non-Covid-19.

Method

Procedure

The present study was cross-sectional and descriptive-analytical. The sample population included first- or second-degree relatives of Covid-19 or non-Covid-19 deceased from June to August 2020 in Gorgan 5th Azar Hospital. Therefore, using convenience sampling, 75 individuals (33 relatives of the deceased Covid-19 and 42 non-Covid-19 deceased) were included in the study. Inclusion criteria were first- or second-degree relationship with the deceased, at least 30 days, and a maximum of three months from the time of death. The questionnaire was forwarded via the virtual networks in Telegram and WhatsApp by a trained person to collect data. In this way, the study's objective was explained to the eligibility, and if they wished, the informed written consent and the questionnaires were given to them to complete. The questionnaire was completed directly by the questioner. The participants were assured that their information remains confidential and do not need to mention their first and last name because the questionnaire is nameless. The study was conducted by the Declaration of Helsinki and approved by the ethics committee at Golestan University of Medical Sciences IRB code IR.GOUMS.REC.1399.215.

Demographic Variables: This questionnaire includes gender, age, marital status, education, ethnicity, medical history, history of depression, the relationship between the person and the deceased (first or second degree), quality of burial, quality of support from relatives, the feeling of being labeled as a Covid-19 patient, the quality of ablution, the quality of support for people with religious status, the status of compliance with the protocol introduced by the Ministry of Health, and quality of receiving a consultation. Theses items ranked on a 3-point scale ( poor, somewhat satisfied, and sufficient).

The Grief Experience Questionnaire (GEQ-34) was designed and developed by Bart and Scott in 1998 to measure grief reactions. It includes seven structural factors and 34 questions (22). The assessed factors include feelings of sin (eight questions), attempts to justify and cope (six questions), physical reactions (five questions), feelings of abandonment (four questions), the judgment of a person or others about the cause of death (four questions), shame and embarrassment (four questions), and notoriety (three questions). It was ranked on a 5-Likert scale (1–5 for never to forever). Acquired scores varied from a minimum of 34 to a maximum of 170. The validity and reliability of this questionnaire in Iran have been confirmed in the study of Mehdipour et al (23).

Analysis

The data were entered into SPSS V.16 and analyzed using descriptive statistics (mean, standard deviation, percentage, and frequency) and analytical statistics. Considering that the Shapiro-Wilk test results showed abnormal distribution in the quantitative variables, the Kruskal-Wallis test was employed to compare the scores of the two groups of deceased relatives. Furthermore, to compare the qualities of burial ceremonies and rituals in the two groups, the Tawkandal test was employed. The significance level was considered 0.05.

Results

The subjects’ age was 15–78 years old with a mean and standard deviation of 33.05 + 19.3 years. 46 (61.3%) women, more than half of them married, more than four-fifths with the diploma and university education, about one-fifth with Turkmen ethnicity, and three-quarters without the disease, but more than two-fifths with a history of depression and the broad majority were second-degree relatives of the deceased (Table 1).

Table 1.

Demographic Profile of Participants.

variables		Covid-19 deceased relatives(n = 33)		non-Covid-19 deceased relatives(n = 42)
		N	%	N	%
Gender	male	15	45.5	31	73.8
	female	18	54.5	11	26.2
Marital status	unmarried	12	36.4	24	57.1
	married	21	63.6	18	42.9
Educational levels	under diploma	9	27.3	4	9.5
	Bachelor degree	17	51.5	15	37.5
	Master degree	7	21.2	23	54.8
Ethnicity	Turkmen	5	15.2	9	21.4
	Fars	19	57.6	28	66.7
	other	9	27.3	5	11.9
Job	student	7	21.2	24	57.1
	employee	6	18.2	9	21.4
	Other	20	60.6	9	21.4
Morbidity background	no	16	48.5	41	97.6
	Yes	17	51.5	1	2.4
Depression	no	13	39.4	30	71.4
	Yes	20	60.6	12	28.6
Medication take	no	32	97	37	88.1
	Anti-depressant	1	3	3	7.1
	Anti-anxiety	0	0	2	4.8
Relative type	first relative	9	27.3	1	2.4
	second	24	72.7	41	97.6

The results of Kendall's tau-b revealed a significant difference between the two groups in terms of quality of burial ceremony, stigma and Covid-19 label, and quality of observance of health protocols (Table 2). Consequently, the deceased caused by the Covid-19 group reported low quality of burial, more perception of the Covid-19 stigma; however, they had good observance of health protocols in the grief ceremony (Table 2).

Table 2.

Comparison of Some Variables of Burial in Relatives of People who Died due to Covid-19 and non-Covid-19.

variables	category	Covid-19 deceased relatives (n = 33)		non-Covid-19 deceased relatives (n = 42)		t	p-value
		N	%	N	%
quality of burial ceremony	Poor	27	81.8	24	57.1	0.24	0.035
	Somewhat satisfied	2	6.1	8	19
	sufficient	4	12.1	10	23.8
quality of support from relatives	Poor	16	48.5	18	42.9	0.12	0.297
	Somewhat satisfied	9	27.3	6	14.3
	sufficient	8	24.2	18	42.9
the feeling of being labeled as a Covid-19 patient	Poor	7	21.2	31	73.8	0.61	<0.001
	Somewhat satisfied	4	12.1	10	23.8
	sufficient	22	66.7	1	2.4
the quality of ablution	Poor	11	33.3	10	23.8	0.03	0.771
	Somewhat satisfied	8	24.2	20	47.6
	sufficient	14	42.4	12	28.6
the quality of support for people with religious status	Poor	8	24.2	6	14.3	0.10	0.402
	Somewhat satisfied	15	45.5	21	50
	sufficient	10	50.3	15	35.7
the status of compliance with the protocol introduced by the Ministry of Health	Poor	3	9.1	7	16.7	0.39	<0.001
	Somewhat satisfied	10	30.3	28	66.7
	Sufficient	20	60.6	7	16.7
Quality of receiving consultation	Poor	18	54.5	21	50	0.11	0.333
	Somewhat satisfied	10	30.3	7	16.7
	sufficient	5	15.2	14	33.3

Additionally, the Kruskal-Wallis test result revealed that the average grief score of relatives of Covid-19 deceased was higher compared to non-Covid-19 deceased. This variation was not statistically significant (p = 0.105) (Table 3). The results of this test revealed that in two areas of grief experience, namely bodily reactions (P = 0.002) and notoriety (p = 0.040), the average score among the relatives of the deceased caused by Covid-19 was significantly higher compared to the non-Covid-19 deceased (Table 3).

Table 3.

Comparison of Mean Grief Scores in Different Areas of Grief Response in Relatives of COVID-19 Induced Deceased Compared to non-COVID-19 Deceased.

variable	Covid-19 deceased relatives (n = 33)		non-Covid-19 deceased relatives (n = 42)		Total		p-value
	Mean	SD	Mean	SD	Mean	SD
Grief( all items)	80.27	31.68	68.09	25.47	73.45		0.105
					28.82
feelings of sin	18.42	8.48	16.33	7.26	17.25		0.33
					7.83
attempts to justify and cope	15.63	7.47	12.90	4.97	14.10	6.44	0.199
physical reactions	12.66	5.06	9.11	3.81	10.68	4.71	0.002
feelings of abandonment	8.96	3.58	8.00	3.29	8.42	3.43	0.248
judgment of a person or others about the cause of death	9.42	4.09	8.04	3.47	8.65	3.79	0.116
shame and embarrassment	8.21	4.00	8.02	3.55	8.10	3.73	0.974
notoriety	6.93	2.84	5.66	2.57	6.22	2.72	0.040

Discussion

Nowadays, Covid-19 has influenced all aspects of human life and has caused grief in communities due to the high mortality rate. The purpose of the present study was to compare the grief in the relatives of the Covid-19 and non-Covid-19 deceased's. The results proved that the relatives of the Covid-19 deceased possess a low quality of burial, more perception of Covid-19 stigma. However, the quality of grief protocols was appropriate compared to other groups. According to social distancing, burial ceremonies, held regularly in Iran in the broad majority of the country's subcultures with a considerable number of individuals, have now been firmly restricted. Not observing these restrictions during the pandemic could cause infection in these meetings. Therefore, health authorities consider certain restrictions to control and prevent this infection compared to before, holding prayers and funeral services are held with as few people as possible, and only a tiny number of first-degree relatives are allowed to attend the funeral. Accordingly, this burial method causes the bereaved to not receive social and emotional support from their relatives, friends, and acquaintances and not experience the grief process in their usual way.

On the other hand, numerous relatives, friends, and acquaintances do not attend the ceremony due to fear of infecting Covid-19 since the death caused by this disease is considered a natural death. Due to the high mortality rate of COVID-19, we can anticipate an increase in prolonged grief rate. In an unexpected death, symptoms of prolonged grief include no traditional grief rituals (e.g., farewell, observation, and burial) and no physical, social support is possible (14,18,20).

On the other hand, the stigma caused by Covid-19 in relatives of the deceased was significantly higher than in the other group. Therefore, the infected individuals are discriminated against and unjust in society, people distance themselves from them, which in turn they hide the virus, and they seek fewer medical services, and as a result, disrupts the control of this virus (24). It is difficult to identify infected individuals with the Covid-19 virus and those not; it causes stigma, discrimination, hatred, and harassment in communities (25). Accordingly, in one case in Bangladesh, people fearing the virus's spread prevented building a hospital to treat Covid-19 patients in their neighborhood (25).

Grief reactions may different in different types of death. The studies revealed specific grief charactristics based on the type of death.The results of study conducted by Houck showed the grief reactions among people who mourned from cancer,AIDS related, and suicide were different.However, it was greater in suicide due to its high stigmatization (26)

In their study Sanders & Adams, found that notable rate of the caregivers of the Alzheimers disease experienced high levels of grief and depressive symtoms (27,28). However, COVID-19 patients are facing with stitma and discrimination around the globe which can lead to grief process limitations (29). Additionally, COVID-19 is a highly contagious disease which can influence its stigmatization.

The relatives of Covid-19 deceased realize that others are discriminating against them due to the trifling death of their lost loved one, and as a result, they have gone through a different experience of grief. The Covid-19 group observed the health protocols better than the other group, which is expected as health and local authorities try to prevent the virus's outbreak by restricting burial and obsessively observing social distance in this case.

The average grief score in the two groups was not significantly different; however, it was higher in the Covid-19 group. Nevertheless, in terms of 7 areas, the results revealed that in terms of physical and stigma reactions in the Covid-19 group, the experience of grief was significantly higher. It seems that the high stigma and perceived discrimination in the first group have led to a notorious experience, which could also lead to severe physical symptoms. Infected individuals with COVID-19 are in quarantine and hospitalization and are disallowed to access their loved ones. Therefore, it seems that these people's death is more painful for their descendants since, unlike the death of non-COVID-19 individuals, close companionship to the infected is impossible for their loved ones in the last days of their life.The results of a study in Dustchland indicated that there were no significant differences between grief levels in people participating before or during the pandemic. However, being recently bereaved during the pandemic elicited more severe grief than before it().Eimsa et al. study showed that COVID-19 bereavement reported more prolonged grief disorder and persistent complex bereavement disorder compared than natural bereavement and unnatural causes (30,31).

Consequently, it is essential to study and recognize differences in individuals’ reactions to the death of first-degree relatives from a clinical perspective. Recognizing the type and degree of individuals’ reactions to the types of absences and the type of reaction appropriate to the degree of relationship could help treat the bereaved (7). This cross-sectional study makes access to relatives difficult, e.g., first-degree. Moreover, observing social distance for interviewing individuals is one of the limitations of this study that should be considered in generalizing the results. Longitudinal studies with a more extensive sample population and with first-degree relatives are suggested.

Conclusion

The present study results revealed no significant difference between the experience of grief in the two groups. However, in the field of physical reactions and stigma, this rate was significantly higher in the relatives of the Covid-19 deceased. Furthermore, this group has experienced more stigma, and the quality of their special burial ceremonies has been significantly lower than the other group.However, therapist and clinicians should be focused on the specific grief characteristics of COVID-19 like hases of bereavement, tasks of mourning and grief stages to awareness form the grief reaction complications. Educational interventions to reduce stigma and discrimination due to death in the community and clinical and psychological support of relatives of the Covid-19 deceased are recommended by compiling proper messages from various channels.