1. Introduction
Death conditions predict symptoms of depression, anger, anxiety, and risk of complicated grief in survivors (Carr et al., 2020). Bad death under normal circumstances is distressing, yet the epidemic has created a context in which the grief of loss by stressors is exacerbated by some psychological distress at the same time. These stressors include social isolation, financial instability, health concerns, worries about other family members, deaths of friends and members of other families, and anxiety about one’s mortality (WHO, 2020). Death in an epidemic can disturb individuals and society (Latrop, 2017). Given the unprecedented challenges, uncertainties, isolation, and social restrictions resulting from COVID-19, it is reasonable to speculate that death and mourning can be greatly affected. As widely reported by the media, many patients worldwide have died alone at home and in hospitals, nursing homes, or other care facilities without the presence of their loved ones (Fang & Comery, 2020). Quarantine and social distancing rules and regulations may limit the capacity of bereaved individuals to seek emotional intimacy and social connection when faced with experiences of loss and grief (Valentine, 2009). These experiences may trigger unbearable grief and even anger for the bereaved people and can cause more problems confronting loss in subsequent life stages. COVID-19 patients could die of widespread physical deterioration, grief, and distress. The pain from this phenomenon can be further increased by forcing separation from loved ones due to strict prevention and control measures (Fang & Comery, 2020).
With the onset of the COVID-19 epidemic, its related problems, such as staying at home, unemployment, the resulting psychological problems, etc., were studied frequently. For instance, Khodabakhshi-Koolaee (2020) examined students’ psychological experiences of living in home quarantine during the COVID-19 epidemic and reported that the students had a unique experience of living in home quarantine due to the outbreak of the COVID-19 epidemic. They also found that living in home quarantine has very different, important, and even lasting psychological effects and consequences (Khodabakhshi-Koolaee, 2020).
COVID-19 has also affected people’s lifestyles and led to a new way of life, which could be the beginning of a new era for people worldwide. For example, during the COVID-19 epidemic, it is impossible to hold a mourning ceremony following customs and traditions, even if the person has died of COVID-19 or for other common reasons. The high number of COVID-19 deaths and the prolongation of social restrictions in holding mourning ceremonies for the dead worldwide may lead to a problem called incomplete grief, inadequate grief, or lack of grief, causing a problem called grief disorder, which if persists, will be associated with many psychological and social consequences. However, when there is an inability to cope with this grieving process, excessive levels of grief negatively affect family, work, and social relationships, even a few months after losing a loved one, leading to a psychiatric problem (Wallace et al., 2020). Interventions against dysfunctional grief should consider its multidimensional features, including individual experiences (such as the formation of the meaning of death and the relationship between survivors and the deceased by cultural factors) (Silverman et al., 2021). 
The emotional experience of a friend’s death and how to deal with it depends on the individual and the cultural context in which it develops (Christ et al., 2022). Grief during the coronavirus pandemic has caused close friends and bereaved family members who are ill, isolated, or at risk to stay home. Bereaved people are discouraged from embracing or touching each other or any physical contact before, during, and after the funeral due to COVID-19. Bereaved people and their supportive community must find new ways to observe these rituals (Goveas & Shear, 2020; Downey, 2020). Thus, grieving for the dead and adapting to it during the epidemic differs from other conditions. Due to the COVID-19 epidemic and the huge and unpredictable developments and challenges caused by it, people worldwide will run into many psychological and social crises, which will cause many difficulties in adapting to the existing conditions. In addition, a significant gap is a lack of a model that facilitates the process of achieving adaptation. Thus, there is a great need for an awareness-raising model that helps COVID-19 survivors to adapt effectively to the grief of COVID-19 victims.
Focusing on effective and practical training on coping with natural grief in the context of the COVID-19 epidemic can prevent possible psychological damage to survivors. The COVID-19 epidemic will continue to profoundly affect many of us. Loss and grief emerge as familiar themes in the lives of many individuals, families, and communities in various contexts. Recognizing the uniqueness of each individual’s loss and grief will provide opportunities to develop effective strategies that facilitate functional adjustment to loss and promote mental health and well-being in this crisis (Zhai & Du, 2020). The COVID-19 pandemic has added another complex layer of grief to the current loss, resulting in a threat to health among those affected by the loss. It has also increased the workload on the family members of the deceased (Hamid & Jahangir, 2020). 
Previous studies have mainly used quantitative methods to understand bereavement during the COVID-19 pandemic. There is little research on adaptation to lived experiences of grief and coping strategies for people who have lost a loved one. In addition, there is no study on developing an effective model for survivors to cope with grief.
As Breen et al. (2021) pointed out, people grieving during the COVID-19 pandemic are at risk for dysfunction, especially if they have separation anxiety, dysfunctional grief, and post-traumatic stress disorder symptoms. Thus, focusing on identifying and treating functional disorders may be important in facilitating the full participation of bereaved people in social and economic life during and after the epidemic. Prevention is low-cost and less time-consuming, but a literature review indicates insufficient study on the prevention of the consequences of grief during the COVID-19 outbreak. Thus, the present study sought to address adaptation strategies and develop a model to adapt to grief among COVID-19 survivors. 

2. Materials and Methods
This qualitative study was conducted with a grounded theory approach to COVID-19 survivors in Tehran City, Iran, in 2021. It sought to explore the nature and process of coping with grief in COVID-19 survivors. Grounded theory is a qualitative research method used to study social processes in human interactions and the factors underlying these processes. This theory examines phenomena in a natural context. Thus, grounded theory is the best choice for formulating a theory or model about a particular phenomenon (Corbin & Strauss, 2008). Grounded theory was adopted in the present study. 
Study participants
The study participants were selected using purposive snowball sampling from the COVID-19 survivors in Tehran in 2021. The inclusion criteria were COVID-19 survivors aged 20 and 60, first-degree relatives of the deceased, at least 10 weeks after losing a loved one, and having minimal literacy. The exclusion criteria include unwillingness to cooperate in the research and having severe physical and psychological problems as diagnosed by a psychiatrist. The researcher was blind to the study participants. Therefore, she asked the COVID-19 survivors to introduce another mourning survivor. Data collection was continued by theoretical sampling until the data saturation.
Semi-structured interview
The required data were collected through semi-structured interviews with 20 COVID-19 survivors. Each interview began with the general question: “What is your relationship with the deceased? What does bereavement mean to you?” “Can you explain to me how your life was after losing your loved one?” “The interview continued with other questions, such as How do you balance family and work duties?” Depending on the responses provided by the participants, other questions were asked to clarify the issue and resolve any possible ambiguities. The interviews were recorded in psychological centers and transcribed immediately after each session. Each interview lasted about 40 minutes. The interview was held in psychological centers affiliated with the Tehran Municipality. The interviews were conducted from September 2020 to April 2021. Interviews were conducted with people who had recently experienced shock and had been referred to mental health centers in Tehran. After completing each interview, its content was immediately transcribed word by word and analyzed simultaneously.
Data analysis
The text of each interview was read several times to develop a general impression of its meaning. In addition, the related statements in the text were identified and codified. All interviews were codified using the same method. To this end, the data extracted from the interviews were codified in three stages: Open, axial, and selective coding. In open coding, the text of the interviews was reviewed several times (Corbin & Strauss, 2008). In addition, significant statements were extracted and coded based on the participants’ reports and the thematic codes developed by the researcher. Moreover, similar codes were merged into the same categories. Then, the resulting categories were compared in terms of similarities and differences. Subsequently, the categories and subcategories with the same themes were merged into one axial cluster as a common axis. Finally, in the last coding step - selective coding, the extracted codes were merged and revised. Moreover, the relationships between the extracted categories and subcategories were revealed by referring to the text of the interviews and identifying the relevant themes. In addition, the most frequently repeated category in the data that could relate the identified categories to each other was discovered. The final data analysis revealed the core category, namely the multidimensional use of self for optimal adaptation to grief. 
Rigor
To ensure the validity of data analysis, the identified categories were shared with the participants, and they were asked to express their views for further clarification. To ensure the reliability of the data, the coding and analysis procedures were reviewed by peer checking. The steps taken to collect and analyze the data were described in detail to ensure the transferability of the findings. In addition, the decisions made during the research process were recorded to make it possible for others to use the present study’s findings in similar situations.

3. Results
All 20 participants participating in the interviews were COVID-19 survivors who had lost one of their loved ones due to COVID-19 and lived in Tehran. The survivors were first-degree relatives of the deceased. The mean age of the participants was 39.5 years. They had at least a diploma and had been grieving for at least 10 weeks. Table 1 presents the participants’ demographic characteristics.



The grounded theory data analysis revealed three main categories: Underlying factors affecting grief, the nature and development of grief, and confronting and managing grief, along with 9 axial codes and 44 codes, as displayed in Table 2. 



Underlying factors affecting mourning
Beliefs and attitudes toward death and the afterlife
Accepting and submitting to the divine command: One of the participants’ reactions in the face of grief and death was acceptance and submission to the divine command. For example, one of the participants pointed out, “death is perhaps the only word that makes you feel that you have no choice but to accept and surrender to the command of God and say goodbye to life in this world” (participant 3). Another participant said, “We have no control over our life and death, and sometimes we must surrender to fate” (participant 6).
Accepting death as a definite fact: According to one of the participants, “death is an inevitable fact, and anyone will face it on a specific day which is unknown to him/her, but it leaves a lot of grief and pain for the survivors” (participant 9). Another participant stated, “I try to feel positive and logically deal with this issue because all human beings in this world end up in death” (participant 5).
Belief in religion and religious teachings: Many participants considered believing in religion, performing their religious duties, and faith in God as one of the factors that enabled them to cope with the death of the deceased. For example, one of the participants was asked: “What are your characteristics and abilities enabling you to cope with this grief?” The participant responded: “Belief in the religion and the teachings of the Qur’an” (participant 17).
Belief in the baselessness and instability of the world: Another reason that made the COVID-19 survivors accept death was the belief in the instability and baselessness of the world: “The world is very baseless, and we cannot count on anything because we have so many plans and ambitions in our lives, but everything was dashed to the ground” (participant 4).
The unknown nature of death: “No one has a bad impression of death because it is a dark space that you do not know what comes afterward. I have not thought much about it yet” (participant 16). “The conditions created by death are vague, and I still could not accept it because it is unknown, and it makes me anxious because no one came from the hereafter to say what that world is like, and thus it is difficult for me to accept something so unknown” (participant 4).
Belief in life after death and re:union:: Many participants believed the hope of re:union: and the afterlife could help them adapt to this grief. For instance, one of the participants pointed out, “I do not know. Perhaps the belief in life after death has enabled me to get along with the death of the deceased” (participant 6). Another participant said, “I do not want to accept that she is no more alive; I just tried to get along with her loss, hoping one day I can hug her again” (participant 16). “One day, I will finally join her and hug her again” (participant 15).
The public reaction to grief 
Lack of understanding of grief and sorrow by the people around 
Many participants who had lost one of their relatively old family members admitted that others told them it was time to die, which greatly bothered them. They also believed that many did not understand their grief because they had no idea how terrible death was due to COVID-19. Thus, they did not understand the suffering of the survivors. One of the participants said, “yes, sometimes I felt that they did not pay attention to our feelings and did not understand our grief” (participant 8). Another participant pointed out, “sometimes it was like this, and no one paid attention to our feelings because they did not understand our feelings” (participant 10).
Fear of others getting infected with COVID-19 
“Yes, sometimes I felt that those around me did not understand my feelings because we did not see each other on the first days of my husband’s death, and they greeted me on the phone fearing I would transmit the coronavirus to them” (participant 20).
Dismissiveness and underestimation 
“I was not in a very good situation, and everyone was trying to calm me down and say that it was normal and it was something that happened to everyone” (participant 15).
Close friends and relatives expressing their sympathy from far away 
Given the need for compliance with the COVID-19 protocols and fear of developing the disease, most participants stated that friends and relatives empathized with them from far away, which was valuable to them. “Because the disease was unknown to people and they feared they might get it, they tried to avoid us. They didn’t join us due to the fear of getting the disease. Thus, they were not physically with us but inquired after us from afar” (participant 4). Another participant said, “relatives and neighbors did not know, but most mutual friends expressed their sympathy with us” (participant 1).
The curiosity of others about the course of the disease and death 
One of the participants stated, “curiosities bothered us the most” (participant 2). “Usually, when I do not know the other person talking to the deceased and seem to ask only out of curiosity about the disease and death of the deceased, I get upset and refuse to talk to him/her” (participant 1).
The special position and role of the deceased
Intimate and friendly relationships with the deceased
“I spent most of my childhood with my grandmother. Even when I got older, we used to go to my grandma a lot, and it was a place for me when I was not fed up with anyone, and I wanted to feel good” (participant 15). “A good, friendly, warm, and intimate relationship that I was proud of” (participant 4).
The emotionally and economically supporting role of the deceased
Many participants believed that the deceased was an economic supporter of the family and that with his/her death, their situation became more difficult, which caused more grief: “Apart from his psychological support, because he financially supported the family, their economic situation will not be favorable after his death” (participant 2). “I feel very lonely mentally and emotionally and, of course, financially, things have become worse and harder for me because I am not employed, and we lived only on my husband’s income” (participant 20).
Love and affection of the deceased to family members and others
“I don’t forget his love and affection and the kind advice he gave us after my father died” (participant 14). “We don’t forget fatherly love and his attempts to save our son, and everybody was talking about it in the family” (participant 9).
The presence of the deceased in life
Most participants stated that because of their close and intimate relationship with the deceased, they felt that the deceased was actively present in and observant of their lives and he/she could listen to them, which in turn would bring them relief and peace: “I believe that her soul is still there and she’s caring for me and listens to what I say” (participant 15).
The nature and development of grief
 Feeling angry with the iranian government and the healthcare system 
Delay in importing COVID-19 vaccines : “I wish the vaccination would have been done sooner and faster. Maybe my father would not have gotten sick because my father also had a heart problem” (participant 10). “My child was very young and died due to illness and lack of vaccine, and I feel he lost his life for no reason” (participant 1).
Lack of equipment and medicines: Many participants blamed the Iranian government and the incompetent healthcare system for not having enough equipment and facilities to control the virus and believed their loved ones lost their life due to the negligence of incompetent government officials: “There were no adequate medical testing equipment facilities to inform the deceased of his infection with COVID-19 earlier” (participant 2). “The reason for countless deaths due to COVID-19 could be the lack of medical facilities” (participant 12).
Forced to be at work during COVID-19: Some participants believed they might have gotten better if they had not been at work and stayed at home, but the mandatory presence at the workplace made them feel worse. In response to the question about the negative factors affecting the course of the disease and death of the deceased, one of the participants pointed out: “He was forced to be present at work” (participant 2).
The failure of medical staff in the timely diagnosis and treatment of COVID-19 patients : “I think the doctors could have noticed the risk of COVID-19 sooner and not underestimated my brother’s illness” (participant 7). “The reason for this was the very bitter event was the mindless person who transmitted COVID-19 to my grandmother and that illiterate doctor who said she did not need a test and she only needed to quarantine herself” (participant 15).
The failure of the ministry of health to provide adequate information : Many participants believed the deceased lacked confidence in the healthcare system in injecting COVID-19 vaccination and had not had adequate information about the coronavirus and proper adherence to health protocols. They also blamed the Ministry of Health for failing to provide sufficient information and gain public trust.
“Definitely, yes, this process was an outcome of the lack of confidence in medical officials who were not aware of the effectiveness of COVID-19 vaccines and prevented public vaccination. If the health organization provided adequate information about the effectiveness of vaccines, my sister would not have died due to the lack of vaccination” (participant 3). 
The nature of death due to COVID-19 
A vain and unreasonable death
One of the themes frequently highlighted by the participants was the belief that their family members lost their lives for no reason and their death could have been prevented. This belief deepened their grief: “Death is still unknown to me in every way. Yes, I feel that she died for no reason and lost her life in vain” (participant 7). “Because my brother was very young, I think he lost his life in vain” (participant 2).
Death in loneliness
One of the reasons that made the COVID-19 survivors more sorrowful was the idea that their loved ones lost their lives in loneliness and solitude: “It’s very painful and sad as she was alone in the hospital at the time of her illness and her family members could not easily see her” (participant 6). “Because my mother died in solitude, innocently, and alone” (participant 14).
Unexpected and sudden death
“It was very sudden and unexpected, and it had nothing for us but suffering and sorrow and a world of regret” (participant 13).
“Two or three days before his death, he was fine again when we said he would be discharged, but once he went into a coma and died the next day, and all this happened in two weeks, and what was left for us was regret, sorrow, and grief that will never end” (participant 9).
Dying selflessly to save others
Many participants believed that the deceased was infected with the coronavirus when caring for a COVID-19 patient, and they considered this as a sacrifice or mission and purpose of the deceased. One of the participants stated, “my sister’s mission was to lose her life to help human beings” (participant 3). Another participant said, “she was infected with the coronavirus because she wanted to help our child who had gotten sick and wanted to help him get well soon” (participant 9).
Blaming oneself for the illness and death of the deceased
Blaming oneself for not being with the deceased during the illness
The death of a loved one is hard by itself, but not being with the deceased in the last days of life is one of the hardest moments that survivors would always remind. For example, one of the participants said, “I was very busy for a couple of weeks, and she was infected with COVID-19 in the same few weeks, and her condition had worsened. Maybe if I kept checking her health and staying with her, I could help her to recover from the disease” (participant 1). “He wanted to see my son fearing that my son would get infected; I said when he came home, he could see him, and my father would not return home and did not see my son, and I’m always regretting I wish I had taken my son so that my father could see him through the glass doors” (participant 11).
Feeling anger and sadness in the process of illness and death
The participants stated that they felt angry and sad because they could not do anything and were also angry about the conditions prevailing in the community and hospitals. one of the participants stated, “there are many bitter and unfavorable things that make me angry and sad when talking about them” (participant 1). 
Impossibility of following the treatment process for the deceased
The participants stated that due to the outbreak of the COVID-19 epidemic, close relatives were not able to follow up on the deceased’s illness regularly, which made them feel guilty. For example, one participant stated, “because I was busy with work, and I thought she was following her illness and treatment herself. Maybe if I could see her, I could force her, and we would go to the hospital sooner” (participant 2).
Feeling guilty about not saving the deceased
Another issue highlighted by the participants was feeling guilty about not trying more to save the deceased from death. They believed that there might have been a solution they did not try. For example, a participant stated, “I did everything I could, but unfortunately, I could not save him from the disease” (participant 9). “It was my great wish that I could save him, but my brother traveled to the hereafter so quickly and sadly” (participant 6).
Blaming oneself for the death of the deceased
Most participants acknowledged that the deceased got COVID-19 from themselves or their relatives. For example, one participant stated, “yes, that’s right. Sometimes I feel guilty and blame myself that my father was infected with COVID-19 because I infected him with the virus” (participant 10).
Remorse for not caring for the deceased at home
Another issue frequently stated by the participants was remorse for not caring for the deceased at home. They believed that taking the COVID-19 patients to the hospital was useless and they could take better care of them at home. For example, one of the participants said, “I feel very guilty because he didn’t like to be hospitalized, and I wish we had kept him and taken care of him at home” (participant 20). Another participant said, “we did everything we could, but I wish we had taken care of him at home and we had the equipment at home” (participant 11).
Confronting and managing grief 
 Confronting the thought of death and the meaning of life 
Reflecting on the philosophy of life and death: Many participants considered reading books and studying the philosophy of life and death to cope with grief. For example, a participant said, “I read materials about the philosophy of life and death” (participant 2). Another participant stated, “I read the books and felt relieved. My face filled with tears as I read each line, but I felt better” (participant 15). Furthermore, a participant said, “I read books on death and accepting death. I talk to my relatives and close friends about the philosophy of life and death” (participant 1).
Using video and audio media: During the COVID-19 epidemic, programs were aired by Iranian TV channels, as pointed out by many participants. For instance, one of the participants said, “Ketab Baz [an Iranian TV show meaning bookworm] happened to be aired during those bitter and tough days, and the guest in the TV show who was talking about death helped my daughter and me in accepting my mother’s death” (participant 8).
Acquiring a deeper understanding and insight into life and death: “The occurrence of death is a shock to human beings to achieve a deeper understanding and attitude that leads to the correction of behaviors. In general, I have found a better outlook on life” (participant 5).
 Inducing life in oneself and other survivors
Emotional and material assistance to the family of the deceased: One of the participants said, “It is difficult for my brother’s family to handle their affairs, and we have to help his family and children emotionally, spiritually, and financially, especially in doing things outdoors. They also need financial aid because his wife is not employed, and the children’s expenses and household were covered only by his income when he was alive” (participant 5).
Engagement in educational and work programs: Many participants reported that continuing to study and pursue hobbies and jobs enabled them to come to terms with and manage their grief: “I’m very interested in my field of study as it helps me to find a successful job in the future. It can be very helpful and save my life” (participant 4).
Fulfilling commitments and responsibilities to children: Another point mentioned by the participants whose spouses had died was the fulfillment of their obligations and responsibilities to their children because they also have to play the role of both the mother and father. For instance, one of the participants said, “I feel responsible for the things I’m committed to doing. I’m trying not to hurt those around me by continuing my grief” (participant 1). Another participant said, “my children and the responsibility I have towards them, which was one of my priorities for my husband, helped me to get along with this grief” (participant 18).
Changing patterns of thinking and behavior towards others and life
Modeling the salient traits and wills of the deceased: One participant pointed out: “As my father sacrificed his life for me, I must think of my child and endure this heartbreaking grief” (participant 10). Another participant said, “She was always trying to make life happy for us, and the main thing is the happiness that he inherited for us, and I try to do the things that she wanted us to do while she was alive, and I wish I could do the same thing she planned to do” (participant 4).
Good manners and kindness to others: One of the ways participants dealt with grief was kindness, good manners, and compassion for others. According to one of the participants, “for example, more compassion - good manners and kindness to all humans and beings help you to get along with your grief” (participant 8). Another participant said, “I have become more compassionate and kind to others” (participant 2).
Correction of actions and behavior: Correction of actions and behavior was another theme highlighted by the participants: “The sudden death of my mother-in-law and my husband made me think about death and loss more frequently and pay attention to my behavior with others, family, children, and people around me so not offend and disturb anyone” (participant 20). Another participant said, “the point is to be more careful about our actions and behavior as the only baggage for the afterlife” (participant 5).
Enjoying life and being together: Being together and living in every moment of life was another theme highlighted by the participants in this study. For example, one participant said, “I believe that I must enjoy life every day and appreciate this blessing. I don’t think I have to work for years and then look forward to enjoying life after retirement because I may not be alive to see that day” (participant 3). Another participant added, “We should enjoy being together and appreciate each other as long as we are alive” (participant 5).
Perceiving life to be meaningless and worthless: Perceiving life to be meaningless and worthless and not worrying about any issue was another strategy recommended by the participants to manage and deal with grief: “It has had a very sad effect, and I found that the world is less valuable than we think” (participant 14). Another participant said, “Life does not mean anything to me with the loss of my mother, which was very unexpected” (participant 15).
Liberty from the world and material things: Another issue stated by the participant was the liberty from the world and material things: “Now I have less attachment to the world, and I try to be more prepared for death” (participant 19).
Defining a paradigm model: As displayed in Figure 1, during the COVID-19 epidemic, causal factors, such as the government, the healthcare system, physicians, the public culture, and the role of the deceased in life have been effective in the development of grief and the experience of negative emotions, such as anger and guilt toward oneself and others, demotivation, reduced life expectancy, and procrastination in doing things. Besides, given the role of the deceased in life, the survivors have had difficulty meeting their emotional and financial needs. The strategies used by many participants were to increase information and awareness about the philosophy of life and death and imitate the traits of the deceased, such as being happy and enjoying life. Moreover, the factors stated by participants influenced these strategies were the belief in death and the afterlife, the public reaction to grief, especially in certain situations, such as pandemics, the role that the deceased played in the survivor’s life, as well as anger at the government and the healthcare system for not providing the necessary facilities, and feeling guilty and blaming oneself for the death of the deceased. The outcomes of these strategies were finding the courage to confront thinking about death and the meaning of life, inducing life in oneself and other survivors, and changing patterns of thinking and behavior in dealing with life and others.



Figure 1 shows the paradigm model of identifying the underlying factors affecting grief, the nature and development of grief, and coping and managing grief. This theoretical model can explain the process of grief during the COVID-19 epidemic based on the personal experiences of COVID-19 survivors. Examples of statements made by the participants were also provided for further clarification.

4. Discussion
The present study’s findings revealed three main categories of underlying factors affecting grief, the nature and development of grief, and confronting and managing grief for COVID-19 survivors. These factors can support resources, facilities, services, tools, and solutions for bereaved survivors, help them control the challenges of playing multiple roles, and provide a favorable response to grief. The first main category included underlying grief factors, such as religious beliefs and attitudes toward death and the afterlife. Accordingly, the participants stated that their beliefs about death and the hope of reuniting the deceased in another world helped relieve them. Another issue highlighted by the participants was the public reaction to grief during the COVID-19 pandemic. The participants stated that others’ reactions could both bother or encourage them. Another underlying factor was the deceased’s role in the survivors’ lives. According to the participants, the more important this role, the more difficult it would be for them to adapt to death and grief. Consistent with the findings of this study, Walsh et al. (2002) showed that people with stronger spiritual beliefs resolve their grief more quickly and completely after the death of a loved one than those who had no spiritual beliefs. Thus, spiritual and religious care should be considered. Although these beliefs may not provide definitive answers to the questions and issues related to spiritual distress, they may help people in distress to identify and map out their sources of spiritual power, regardless of their religion or beliefs (Aguiar et al., 2020). 
Uncertainty, disbelief, and surreal feelings were constant in the losses that occurred in an emergency. Besides, these feelings of disbelief make it difficult to fully understand the reality of death and the beginning of the mourning process (Worden, 2009). Accordingly, although religious belief does not translate into action, it can help people cope with grief. Like other Muslim communities, people visit, mourn, and support the bereaved in large numbers, including neighbors, friends, relatives, and other acquaintances. They live with bereaved families who help the bereaved overcome their grief (Hamid et al., 2019; Hamid & Jahangir, 2020). However, the COVID-19 epidemic and social isolation measures have changed the whole structure of mourning everywhere (Hamid & Jahangir, 2020). A huge increase in deaths due to the COVID-19 outbreak has had a pervasive impact on cultural norms, rituals, and common social practices related to death and mourning and potentially exacerbated complex grief (Mayland et al., 2020). Hamid and Jahangir (2020) found that many participants reported that the death of a friend during the COVID-19 pandemic is less threatening and painful than people’s horrific opinions, and how people look at them is no less than death in itself.
Risk factors that can contribute to “complex grief” are not limited to the nature of death; for example, sudden, traumatic, or violent deaths, resulting in unpreparedness or little opportunity to say farewell to the deceased (Burke & Neimeyer, 2013). According to Breen et al. (2022), the mortality of vulnerable patients could be significantly reduced even with respiratory assistance and other types of medical support because families suffering from helplessness and guilt cannot rescue their loved ones at the end of their lives. Many participants in the present study stated that their grief was due to anger at the government and the healthcare system because of the failure to provide facilities and implement COVID-19 vaccination programs. A factor that complicates grief is the unexpected speed or nature of death. As Coleman (2003) noted, transferring dying patients from home to the hospital in their final days, both during the transition and after death, is a source of distress for family members. In addition, isolation and physical barriers may prevent sensitive and timely communication and limit opportunities for saying farewell to the dying patient (Mayland et al., 2020). In the face of sudden death, bereaved people often have little time to face and prepare for the loss (Fang & Comery, 2020). The failure to say farewell to a loved one, before and after death, is a complex factor in grief, as it is associated with disbelief, denial, rejection, and coping with loss (Hernández-Fernández & Meneses-Falcón, 2021). As Carr (2009) pointed out, bereaved people who believe that their loved one died too soon, too young, or unjustly due to lack of proper care may experience anger and a tendency to blame, find meaning, or seek revenge for the culprits of the loss.
Another major category of grief management was the strategies used by the participants to manage grief, including thinking about death and the meaning of life, inducing life in oneself and other survivors, and changing patterns of thinking and behavior toward others and life. Borghi and Menichetti (2021) pointed out that the need to focus on other family member’s physical or mental health helped them develop a sense of usefulness, power, and self-confidence. Consistent with the findings of the present study, Neimeyer et al. (2010) stated that according to the theory of meaning, reconstruction narrative is an activity that allows one to rewrite the experience of loss, explain it by reorganizing, deepening, or expanding one’s beliefs and narratives to embrace reality. Dealing with faith or hope helped to cope with death with thoughts such as “It was destiny” or “I hope he/she will be buried in a good place.” Faith and spirituality represented an internal anchor for families looking for meaning in an unpredictable and uncontrollable situation such as the COVID-19 pandemic. They managed to frame a stressful situation into a larger, more benevolent system of meaning (Borghi & Menichetti, 2021). Menzies et al. (2020) pointed out that death due to COVID-19 may violate core beliefs about the nature of death, the world, and the future.
In general, the COVID-19 pandemic is a relatively new phenomenon leading to changes in the conditions of grief and mourning ceremonies change, and people in the community treat the survivors differently, which can cause harassment or support from others. The economically and emotionally supportive role of the deceased in life causes survivors to experience, in addition to the heavy burden of grief, life problems, and being without support due to the unjust death of the deceased. One of the unpleasant and negative feelings that the survivors usually experience is anger at themselves and the healthcare system. They feel guilty about not being able to do anything. They are angry at the government and the healthcare system for failing to provide adequate medical equipment to treat patients. Death in loneliness and solitude is one of the outcomes of the COVID-19 outbreak and increases the burden of grief for survivors. Thus, they try to reconstruct the meaning of life, death, and the world after death to cope with this definite fact. Many survivors stated that the death of their loved ones caused them to look at life differently and perceive it as a blessing. One way to deal with this grief was to follow the behavioral patterns and life of the deceased. Therefore, they thought the deceased was still alive and watching over their lives, which induced hope in them. They believed that they would join the deceased in another world after death. The COVID-19 survivors stated that they were more offended by the reaction of those around them and the public, who did not give them a chance to mourn, than by the grief over the death of their loved one. No mourning ceremony was held, and even when it was held, people and relatives did not support the family at the ceremony and were worried about being infected. The behaviors of those around them made them more upset.
Qualitative research is rooted in the participants’ living conditions and cultural, social, and religious factors, which may make the results unique and can be further generalized to communities closer to the research community. In this case, the culture of the Eastern and the Middle Eastern communities and the Islamic beliefs of Islam play a very strong role. Besides, the interviews were held with delay due to the tough conditions suffered by the survivors when remembering the death of their loved ones and their psychological conditions. 
Given that Islamic religious beliefs prevail in Muslim countries and Muslims believe in life after death and submission to God, future studies need to focus on the effects of religious and spiritual beliefs of bereaved people in the face of grief. Besides, religious and spiritual interventions developed based on Islamic principles and Iranian culture are more effective for bereaved persons.

5. Conclusion
This study showed that bereaved people adopt religious/spiritual and problem-oriented coping strategies after the grief period. For example, they may resort to religious beliefs about death and the afterlife, and thus they tend to surround God. Because God has predestined everything for His servants, and the life and death of human beings are in God’s hands. Redefining the meaning of life, thinking more about death and the absurdity of the world, caring more for family and children, striving to be a better human being, treating others with kindness, not caring about material things, and finally trying to satisfy the wishes of the deceased were some strategies used by the Iranian COVID-19 survivors deal with the grief of the death of their loved ones. 

Ethical Considerations

Compliance with ethical guidelines
This article reports the results of a PhD dissertation, registered at the Iran National Committee for Ethics in Biomedical Research (Code: IR.IAU.TNB.REC.1400.059).

Funding
This study was extracted from PhD dissertation of Jamileh Mansoori, approved by Department of Counseling, Islamic Azad University, Science and Research Branch.

Authors' contributions
Conducting research, data collection and data analysis: Jamileh Mansoori; Conceptualisation, study design, writing the original article, review, edditing and final approval: Anahita Khodabakhshi-Koolaee; Data analysis: Mohammad Reza Falsafinejad; Co-advisor: Leila Kashani Vahid.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the participants. 



References
Aguiar, A., Pinto, M., & Duarte, R. (2020). Grief and mourning during the COVID-19 pandemic in Portugal. Acta Medica Portuguesa, 33(9), 543-545. [DOI:10.20344/amp.14345] [PMID]
Borghi, L., & Menichetti, J. (2021). Strategies to cope with the COVID-related deaths among family members. Frontiers in Psychiatry, 12, 622850..‏ [DOI:10.3389/fpsyt.2021.622850] [PMID] [PMCID]
Breen, L. J., Mancini, V. O., Lee, S. A., Pappalardo, E. A., & Neimeyer, R. A. (2022). Risk factors for dysfunctional grief and functional impairment for all causes of death during the COVID-19 pandemic: The mediating role of meaning. Death Studies, 46(1), 43–52. [DOI:10.1080/07481187.2021.1974666] [PMID]
Breen, L. J., Lee, S. A., & Neimeyer, R. A. (2021). Psychological risk factors of functional impairment after COVID-19 deaths. Journal of Pain and Symptom Management, 61(4), e1-e4 [DOI:10.1016/j.jpainsymman.2021.01.006] [PMID]
Burke, L. A., & Neimeyer, R. A. (2013). 11 Prospective risk factors for complicated grief. New York: Routledge.‏
Carr, D., Boerner, K., & Moorman, S. (2020). Bereavement in the time of coronavirus: Unprecedented challenges demand novel interventions. Journal of Aging & Social Policy, 32(4-5), 425-431. [DOI:10.1080/08959420.2020.1764320] [PMID]
Carr, D. (2009). Who’s to blame? Perceived responsibility for spousal death and psychological distress among older widowed persons. Journal of Health and Social Behavior, 50(3), 359-375. [DOI:10.1177/002214650905000308] [PMID]
Christ, R. C., Varga, B. A., Helmsing, M. E., & van Kessel, C. (2022). Situating Covid-19 within the context of death and grief. In W. Journell (Ed.), Post-pandemic social studies: How COVID-19 has changed the world and how we teach (pp. 28-40). New York: Teachers College Press. [Link]
Coleman, E. A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555 [DOI:10.1046/j.1532-5415.2003.51185.x] [PMID]
Corbin, J., & Strauss, A. (2008). Qualitative research: Techniques and procedures for developing grounded theory. California: SAGE Publications. [Link]
Downey, A. M. (2020). Mourning our losses: Finding response (-ability) within COVID-19. Antistasis, 10(3), 1-4.‏ [Link]
Fang, C., & Comery, A. (2020). Understanding grief in a time of COVID-19-a hypothetical approach to challenges and support. Advance. Preprint. [DOI:10.31124/advance.12687788.v1]
Goveas, J. S., & Shear, M. K. (2020). Grief and the COVID-19 pandemic in older adults. The American Journal of Geriatric Psychiatry, 28(10), 1119-1125.‏ [DOI:10.1016/j.jagp.2020.06.021] [PMID] [PMCID]
Hamid, W., & Jahangir, M. S. (2020). Dying, death and mourning amid COVID-19 pandemic in Kashmir: A qualitative study. Omega, 85(3), 690–715. [DOI:10.1177/0030222820953708] [PMID]
Hamid, W., Jahangir, M. S., Khan, T. A., & Maqbool, T. (2022). Role of technology in restructuring the traditional practices around death and mourning in Kashmir. Death Studies, 46(4), 832–841. [DOI:10.1080/07481187.2019.1701146.] [PMID]
Hernández-Fernández, C., & Meneses-Falcón, C. (2022). I can’t believe they are dead. Death and mourning in the absence of goodbyes during the COVID-19 pandemic. Health & Social Care in the Community, 30(4), e1220–e1232.. ‏ [DOI:10.1111/hsc.13530] [PMID] [PMCID]
Khodabakhshi-Koolaee, A. (2020). Living in home quarantine: Analyzing psychological experiences of college students during Covid-19 pandemic. Journal of Military Medicine, 22(2), 130-138. [Link]
Lathrop, D. (2017). Disenfranchised grief and physician burnout. Annals of Family Medicine, 15(4), 375-378. [DOI:10.1370/afm.2074] [PMID] [PMCID]
Mayland, C. R., Harding, A. J., Preston, N., & Payne, S. (2020). Supporting adults bereaved through COVID-19: A rapid review of the impact of previous pandemics on grief and bereavement. Journal of Pain and Symptom Management, 60(2), e33-e39. [DOI:10.1016/j.jpainsymman.2020.05.012] [PMID] [PMCID]
Menzies, R. E., Neimeyer, R. A., & Menzies, R. G. (2020). Death anxiety, loss, and grief in the time of COVID-19. Behaviour Change, 37(3), 111-115.‏ [DOI:10.1017/bec.2020.10]
Neimeyer, R. A., Burke, L. A., Mackay, M. M., & van Dyke Stringer, J. G. (2010). Grief therapy and the reconstruction of meaning: From principles to practice. Journal of Contemporary Psychotherapy, 40, 73-83. [Link].
Silverman, G. S., Baroiller, A., & Hemer, S. R. (2021). Culture and grief: Ethnographic perspectives on ritual, relationships, and remembering. Death Studies, 45(1), 1-8.‏ [DOI:10.1080/07481187.2020.1851885] [PMID]
Valentine, C. (2009). Negotiating a loved one’s dying in contemporary Japanese society. Mortality, 14(1), 34-52 [DOI:10.1080/13576270802591269]
Wallace, C. L., Wladkowski, S. P., Gibson, A., & White, P. (2020). Grief during the COVID-19 pandemic: Considerations for palliative care providers. Journal of Pain and Symptom Management, 60(1), e70-e76. [DOI:10.1016/j.jpainsymman.2020.04.012] [PMID] [PMCID]
Walsh, K., King, M., Jones, L., Tookman, A., & Blizard, R. (2002). Spiritual beliefs may affect the outcome of bereavement: Prospective study. BMJ (Clinical research ed.), 324(7353), 1551. [DOI:10.1136/bmj.324.7353.1551] [PMID] [PMCID]
World Health Organization. (2020). Mental health and psychosocial considerations during the COVID-19 outbreak. Geneva: World Health Organization. [Link]
Worden, J. W. (2009). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York: Springer Publishing Company. [DOI:10.1891/9780826101211]
‏ Zhai, Y., & Du, X. (2020). Loss and grief amidst COVID-19: A path to adaptation and resilience. Brain, Behavior, and Immunity, 87, 80-81. [DOI:10.1016/j.bbi.2020.04.053] [PMID] [PMCID]