1. Introduction

The incidence of contagious diseases that turn into epidemics, such as COVID-19, has led to significant health and economic challenges as a result of various environmental and societal changes on a global scale and because of ongoing economic growth ( 1 ). Changes to the quality of economic activities worsen the management of new contagious diseases that can be transmitted due to human contact and presence. The increase in specialization in economic areas, the development of markets, and their globalization increase the threat of people coming in contact with sources that increase the incidence of very infectious diseases ( 2 , 3 ). Therefore, the existing adverse economic consequences caused by the Coronavirus disease in the world economy have been one of the many problems ( 4 ). Research showed that these infections or the associated threats can adversely affect production. In addition, supply chains may be broken or disrupted by these outbreaks. Most pandemics significantly reduce economic production globally and increase unemployment ( 1 , 4 ). On the other hand, what governments do to control the spread of the disease and deaths caused by it have caused a significant decrease in employment and economic activity globally. It should be noted that if social rules to cut down on the spread of COVID-19 become strict, unemployment increases, and all economic activities decrease, causing governments to face exchange problems ( 4 ). The impacts of the COVID-19 pandemic on mortality rates have prompted ethical concerns regarding the value of human existence, in addition to facing the financial challenges of this era. Studies showed that valuing how groups or individuals live based on their participation in the economic production causes how the lives of elderly and low-income people be undervalued in comparison with other people’s lives ( 4 , 5 ). Such an approach may not fully appreciate the unique challenges faced by women as a group who, on average, earn less (i.e., income related to market activities) compared to men. Moreover, the very approach neglects the value of women’s unpaid work in the family and their routine roles as the important caregivers of the family ( 4 , 6 ).

The restrictions caused by COVID-19 have put people at risk of developing symptoms and disorders of acute stress and led to more common psychological problems, emotional problems, depression, anxiety, bad mood, aggression, and sleeplessness caused by anxiety ( 7 ). Studies showed that grave concerns are raised about children’s mental health due to the COVID-19 epidemic ( 8 , 9 ), and the discussion about the mental costs of the disease is still ongoing ( 10 , 11 ). Previous studies showed that children quarantined in areas heavily affected by epidemics, experience post-traumatic stress disorder (PTSD) as parents reported ( 12 ). Besides recording mental health of children throughout the pandemic, it is essential to identify the high-risk and protective components to determine the at-risk subgroups and take appropriate measures to protect them from mental health issues ( 13 ).

Parents typically have the most frequent interactions with their children. The World Health Organization (WHO) suggests that parents should talk about COVID-19 to their children in a truthful and age-friendly manner that meets their obsessions and alleviates their anxiety ( 14 ). By doing so, entering effective conversation with parents and children can be considered a factor to protect children’s mental health ( 13 ). A previous study indicated that the socio-ecological impact of this epidemic on children’s mental health is unclear, which may create challenges and have unfortunate consequences in the future ( 15 ). On the other hand, prior investigations on epidemics and pandemics have underlined the need to explore the effect of the socioeconomic burden of COVID-19 on the mental health of parents and children ( 15 , 16 ). Our study aimed to investigate the economic and social burden of COVID-19 on children’s health in Iran with the mediation of parents’ general health to address these gaps in the literature ( Figure 1).

Figure 1. The figure shows the theoretical model of the research.

2. Methods

2.1. Study Design and Participants

The statistical population of the present cross-sectional study was the parents of children aged between 5 and 18 years in 2021. The study participants were chosen from different geographical regions of Iran. They were randomly selected among the people living in 5 provinces of Iran (Mashhad, Kermanshah, Zahedan, Tabriz, Chaharmahal and Bakhtiari).

To collect data, we utilized an online application to distribute a questionnaire. The participants were asked to fill out the survey anonymously. We send the survey hyperlink to the participants through different social networks, such as WhatsApp, Telegram, and Instagram. To address any questions or concerns about the research questions, we included a phone number in the hyperlink.

We chose 500 families with kids and teenagers between 5 and 18 years of age to participate in the study. The inclusion criteria were residing in one of the selected cities for the minimum of a year, having a child within the age range of 5 to 18 years, and being able to read and do the survey. The exclusion criteria were: parenting a child with intellectual disabilities or serious physical illness, unwillingness to participate in the study, and leaving the questionnaire incomplete.

2.2. Instruments

The demographic variables of interest were sex, age, children’s education, parents’ education, and economic and social status. In addition, in this study, questionnaires on the economic and social burden of COVID-19, general health, child health, and place of residence landscape were used to collect the data.

2.2.1. Socioeconomic Burden of COVID-19

The socioeconomic effect of COVID-19 was assessed using the COVID-19 checklist designed for families and societies ( 17 ). This checklist was designed by Santana and has been translated and used in 13 countries. It measures various aspects such as the characteristics of residence, house, effects of COVID-19 on activities in the community, diseases, and access to healthcare ( 17 ). Upon the approval of the checklist designers, we chose the questions that were meant to measure socioeconomic burden. Multiple Correspondence Analysis (MCA) was employed to explore and pinpoint the various factors and components involved, leading to the conclusion that the size and KMO=0.777 of the sample sufficed. According to MCA output, the ten questions measure three factors, respectively: questions 1-3 (social concerns), questions 4-7 (economic concerns), and questions 8-10 (family concerns). The three components accounted for 64.96% of the total variance. The answers in this checklist are rated on a 5-point Likert scale: not at all (1 point), slightly (2 points), sometimes (3 points), very often (4 point), and extremely (5 point). Within this ongoing survey, Cronbach alpha coefficient was estimated for the components as following: social concern (0.842), economic concern (0.772), and family concern (0.645), respectively.

2.2.2. General Health Questionnaire (GHQ-12)

This scale, designed by Goldberg ( 18 ), is a highly used scale concerning individuals’ general health. This instrument has a 60-question form and three 30, 28, and 12-question forms. It has been translated into many languages and is widely used in general and clinical populations ( 19 ). A 12-question form was used to assess people’s general health in this study. The instrument has two dimensions of positive and negative mental health. Its positive dimension consists of six questions, and six other questions measure negative mental health. The 12-question form is graded on a Likert scale (much lower than usual, lower than usual, usually, more than usual). The instrument is scored in two ways: (0-1-2-3) and (1, 0, 0, 1), ( 19 - 21 ). In this study, the scoring method of (0-1-2-3) was used. The reliability and validity of this instrument in Iran were investigated and substantiated by Yaghubi and colleagues ( 19 ). In the present study, the Cronbach alpha coefficient for the mental health dimension was calculated to be 0.873, while the value for its negative dimension was found to be 0.860.

2.2.3. Child Health Questionnaire

This instrument was introduced by Landgraf and Abtes ( 22 ), and is a popular scale to measure children’s health or health-related quality of life ( 23 ). In this study, a 28-item form was used to measure children’s health condition, the construct validity of which was substantiated by Golzarpour and co-workers in Iran. In the validation process, the instrument was reduced to 22 items ( 24 ). The questionnaire content is rated on a Likert scale. A number of items are rated between 1 and 4 while others are rated between 1 and 5 ( 25 ). In this study, Cronbach alpha value was estimated to be 0.933, 0.900, 0.891, 0.908, 0.897, 0.888, and 0.927 for the dimensions of mental health, child satisfaction, child movement, child performance, parents’ concern, parents’ restrictions, and child’s general health, respectively.

2.2.4. Social and Economic Status

The 5-question COVID-19 survey designed for families and populations was employed to assess the socio-economic standing of the household ( 17 ) for having or not having of car, house, laptop, dishwasher, and refrigerator. Multiple Correspondence Analysis (MAC) was utilized to explore the number of related factors and items, and according to the results, five items measure one factor, accounted for 37.25% of the overall variation.

2.2.5. Place of Residence Landscape

COVID-19 checklist raises questions for families and societies to evaluate the place of residence landscape ( 17 ) which was about the surrounding view of the house, i.e. having or not having balcony.

2.3. Statistical Analyses

In this study, t-test was applied using SPSS version 26 to analyze the data. Moreover, SEM was applied using AMOS version 26 to test the proposed model.

3. Results

3.1. Demographic Characteristics of the Participants

The mean age and standard deviation of the parents and their children were 37±7.2 and 11±3.4, respectively. Other demographic characteristics are presented in Table 1.

3.2. Research Model

3.2.1. Examining Direct Paths

Based on the fitted model results (CMIN=2.81, GFI=0.943, CFI=0.979, RMSEA=0.060), a negative and significant correlation was found for the socioeconomic burden of COVID-19 and parents’ general health (β=-0.383, P<0.001) (Table 2). Furthermore, a significant and positive correlation was observed between the economic and social status and parents’ general health (β=0.138, P=0.014), as well as the place of residence landscape and parents’ general health (β=0.243, P<0.001). A negative and significant correlation was also found between the socioeconomic burden of COVID-19 and child health (β=-0.202, P=0.003). The parent’s general health was positively and significantly related to the child’s health (β=0.398, P<0.001) (Table 2). Based on the coefficients of determination, the socioeconomic burden of COVID-19, parents’ socioeconomic status, and place of residence landscape accounted for about 25% of the changes in parents’ general health. In addition, the socioeconomic burden of COVID-19 and parents’ general health simultaneously explained 26% of the changes in child health ( Figure 2).

Figure 2. The figure shows the results of the analysis examining the relationship between the predictor variables and child health. SEB: Socioeconomic Burden; C.S: Social Concerns, C.E: Economic Concerns, C.F: Family Concerns; CHQ: Child Health; M.H: Child Mental Health, S.Sat: Child Self-Satisfaction; Mov.St: Child Movement Status; Perf: Child Performance; Uneasy: Parents’ Concern; Par.Lim: Parents’ Limitation; G.H: Child’s General Health; GHQ: Parents’ General Health; P.M: Positive Dimension of Mental Health; N.M: Negative Dimension of Mental Health; P.R.L: Place of Residence Landscape; SES: Social and Economic status

3.2.2. Examining Indirect Paths

According to the fitted model and the Sobel test (26), each of the three variables of the socioeconomic burden of COVID-19(β=-0.15, z=-3.58, P<0.001), place of residence landscape (β=0.09, z=3.3.49, P<0.001) and family’s socioeconomic status (β=0.05, z=2.29, P=0.021) were indirectly and significantly related to child health. In the mentioned model, a statistically significant correlation was found between the place of residence landscape and social and economic status (P<0.001, r=0.41).

4. Discussion

The COVID-19 pandemic required a set of prescribed policies, including economic quarantine and physical distancing, to maintain public health and ensure the prospects of communities. The limitations caused by this disease have put people at risk of developing acute stress symptoms and disorders. Thus, the present study aimed to investigate the social and economic burden of COVID-19 on children’s health in Iran with the mediating role of parents’ general health.

Our results revealed that the socioeconomic burden of COVID-19 was negatively and significantly associated with parents’ overall health. The findings of other studies revealed that with the emergence of the pandemic, socioeconomic insecurity has increased in families. This, in turn, was associated with lower mental health, especially in low-income families ( 27 , 28 ). The pandemic along with the manipulative and authoritative policies, such as the mandatory quarantine, keeping a physical distance, and social isolation were associated with lower mental well-being. These conditions were even worse for parents who worked outside home. The pandemic was associated with higher financial insecurity and longer time spent on taking care of children at home. With this regard, men and women did not experience the same pressure or burden. Similarly, households of varying economic statuses, including both affluent and impoverished ones, were also affected ( 27 ). Bayrakdar and Guveli showed that children in low-income households went to schools with limited facilities to cater for e-learning ( 29 ). The non-consistent imposition of post-pandemic burden suggests that general policy-making must consider the existing inequalities. Parents who worked outside home, particularly mothers, enjoyed fewer emotional and financial sources. The socioeconomic burden of COVID-19 can be reduced by further supporting child care and home education, such as non-financial support to share educational content. These inequalities need to be considered in planning for support programs for people in society ( 27 ). It can be argued that socioeconomic programs that address people’s problems and prevent them may improve community’s mental health ( 28 ).

As the present study revealed, there was a significant and positive correlation between the place of the residence landscape and parents’ general health. Similar to our study, the results of other investigations carried out in the U.S. showed that access to the place of the residence landscape, such as parks, was correlated with higher mental health of parents and children. Adequate access to parks led to parents’ greater physical activity and parent-child cooperation in outdoor activities during the globally diseased conditions. Proximity and availability of parks can be a considerable resource for promoting individuals’ and families’ health ( 30 ). A review of the literature showed that the COVID-19 pandemic increased anxiety, depression, and stress ( 31 , 32 ). Events affecting populations prove the need for population-scale facilities to take care of mental health in stressful conditions ( 30 , 33 - 35 ).

Studies showed that visits to the place of the residence landscape, such as green spaces, were multiplied during the pandemic. During the COVID-19 pandemic, the frequency of visits to residential landscapes, including green spaces, significantly increased. This phenomenon can be attributed to the restrictions imposed on public gathering places and the heightened awareness of the benefits associated with visiting one’s residential landscape ( 30 , 36 ). The central point is that, consistent with our results, during the epidemic, green spaces located in residential areas have reduced manifestations of depression and anxiety ( 30 , 37 - 39 ).

This study revealed that the socioeconomic burden of COVID-19 was negatively associated with children’s health. A review of the literature showed that the epidemic increased socioeconomic insecurity in mothers ( 40 ). This issue is worrying due to its consequences for breastfeeding and children’s health and growth. These results indicated that health policymakers need to assess the lack of universal support policies and provide better assistance and support to the groups at risk, such as mothers, to control the increase in socioeconomic inequalities and psychological burden on mothers. The lack of health of mothers increases the subsequent adverse effects on children’s health ( 41 ), especially through higher economic insecurity and lower psychosocial well-being in those already in low socioeconomic positions. Although families were provided with support packages during the pandemic, these packages may not have been enough for all households, especially low-income households. Therefore, future policies should think of new ways to help families, especially families with younger children or the poor, in order to prevent the rise of the socioeconomic inequalities ( 41 ).

In our study, a significant and positive correlation was observed between parents’ general health and children’s health. Parent depression has been the primary factor predicting children’s behavioral disorders. Also, behavioral disorders in children reflect parents’ mental problems because the mental disease of each parent increases the possibility of mental disorders in the child ( 42 ). Children’s behavioral problems and parents’ psychological demands were common predictors of the general health of all parents ( 43 ).

4.1. Limitations

There were certain limitations in this study. The present study depended on self-reported information, which could result in some sort of bias in responses, including the underestimation or overestimation of facts about health conditions or can also lead to bias in recalling information. Since this was a cross-sectional study, the researchers cannot infer the causality of the correlation between the socioeconomic burden of COVID-19 and the mediating role of parents’ general health in children’s health. There is a possibility that the mental health of families that already had socioeconomic and psychological problems was more affected by this epidemic; however, this requires a longitudinal study.

5. Conclusions

The socioeconomic burden of COVID-19 has put people at risk of acute stress. The present study showed that the socioeconomic burden of this disease negatively affected parents’ and children’s mental health and increased the socioeconomic insecurity in families. Although the results related to the place of residence landscape positively affected parents’ mental health, this situation likely resulted in improved mental health for both parents and their children.

Acknowledgment

We thank all the individuals who participated in this study.

Ethical Approval

This research was approved by the Ethics Committee at the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran, with the code of IR.USWR.REC.1400.058. Also, written informed consent was obtained from the participants.

Authors’ Contribution

Majid Golzarpour: Substantial contributions to the conception and design of the work, drafting the work. Homeira Sajjadi: Substantial contributions to the conception and design of the work, drafting the work. Paula Santana: Contributions to the conception of the work, drafting the work and reviewing it critically for important intellectual content. Gholamreza Ghaedamini Harouni: Substantial contributions to the acquisition, analysis, or interpretation of data, drafting the work. Claudia Costa: Contributions to the conception of the work, drafting the work and reviewing it critically for important intellectual content. Arash Ziapou: Substantial contributions to the acquisition, analysis, and interpretation of data, drafting the work. Seyed Amar Azizi: Substantial contributions to the acquisition and interpretation of data, drafting the work. Sima Afrashteh: Contributions to the conception of the work, reviewing the work critically for important intellectual content. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work, such as the questions related to the accuracy or integrity of any part of the work.

Funding

No funding.

Conflict of Interest

None declared

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