Qom University of Medical Sciences Journal

Introduction
The outbreak of coronavirus disease 2019 (COVID-19) not only threatened the physical health and caused death in some cases, but also caused psychological problems and unbearable pressures. Anxiety and worry in people often increase under public health crises. Being worry during a pandemic can lead to increase in obsessive thoughts and develop clinical anxiety and maladaptive coping behaviors (e.g., addictive behaviors). Lifestyle changes for curbing the spread of COVID-19 may exacerbate anxiety levels. Anxiety caused by COVID-19 is common and seems to be mostly due to the fact that it is unknown and creates ambiguity in people about the virus. Fear of the unknown reduces the perception of safety in humans and has always been a source of anxiety for mankind. This study aims to investigate the prevalence of the fear of COVID-19 and anxiety among people aged >18 years in Kermanshah, Iran
Methods
This is a descriptive cross-sectional study. The study population consists of all people aged >18 years in Kermanshah city in 2021, which was 619315 people based on the data from the national integrated health system (SIB). Of these, 400 men and women were selected. The sample size was determined 383 using the Cochran's formula at 95% confidence interval, which was increased to 400 considering a sample dropout. The data collection tool was a questionnaire with three parts: Demographic form (age, gender, educational level, marital status, employment status, and size of household), fear of COVID-19 scale with 21 items (fear of being infected, fear of infecting others, fear of quarantine, fear of financial problems, fear of physical and mental problems, fear of lack of access to resources such as personal protective equipment, fear of being rejected in case of infection, etc.), and the Beck Anxiety Inventory.
Due to the lack of a standard questionnaire to assess fear of COVID-19 in Iranian samples, the questionnaire was designed by reviewing previous related studies and extracting variables affecting the fear of COVID-19. To determine the face validity of the questionnaire, all questions were sent to 20 people over 18 years of age in Kermanshah to ask their opinions about the comprehensibility of the items. In examining the content validity, the opinions of four experts in clinical psychology and health education were used. Then, the content validity ratio and the clarity and simplicity of the items were examined. The results showed that the questionnaire had high face validity and content validity. For the reliability, a Cronbach's alpha value of 0.87 was obtained. The scoring was based on the five-point Likert scale from not at all (0) to very high (5). A score of 0-28 indicates low fear, a score of 29-56 indicates moderate fear, and a score > 56 indicates high fear of COVID-19. Data was analyzed using descriptive and inferential statistics in SPSS software, version 19. The significance level was set at 0.05.
Results
The mean age of participants was 32.3±12.1 years; 47% were single and 53% were married; 42% were female and 58% were male; 37% were unemployed, 34% were self-employed, and 29% were employed. The mean scores of the fear of COVID-19 and anxiety in participants were 42.9±7.6 and 17.9 ±10.8, respectively. It was found that 5.5% had low fear, 75.3% had moderate fear and 19.2% had high fear. Moreover, 60.1% had mild anxiety, 38.1% had moderate anxiety and 1.8% had severe anxiety. Among the demographic variables, marital status, educational level, and size of household had a significant relationship with the fear of COVID-19 (P <0.001). Those with higher educational level, married people, and those with a large household size had higher fear. Only the educational level had a significant relationship with anxiety (P<0.001), such that people with higher educational level were more anxious. The fear of COVID-19 was positively and significantly correlated with anxiety.
Discussion
The results of the present study showed that 94.5% of the people in Kermanshah had moderate to high fear of COVID-19. Consistent with the present study, the results of Titov et al. showed that 93.8% of the participants had concerns about COVID-19 due to being worry about job loss, financial insecurity, access to basic necessities of life, coping with isolation, and lifestyle changes. In our study, 39.9% of people in Kermanshah had moderate to severe anxiety. Besirli et al. showed that 60.5% of participants had low anxiety, 34% had mild to moderate anxiety, and 5.5% had severe anxiety. Our findings showed that the fear of COVID-19 had a positive and significant relationship with anxiety in people. In this regard, the results of Vujanovic and Zhooriyati showed that worry about COVID-19 were associated with more severe symptoms of anxiety and depression.

One of the limitations of this study was its cross-sectional design, which can affect the possibility of a causal path between independent and dependent variables. Another limitation was the use of a self-report tool for measuring anxiety and fear, which can affect the accurate estimation of these variables. According to the results of the present study, to maintain the mental health of the society during the pandemic, it seems necessary to identify people prone to mental disorders and provide appropriate psychological interventions to them.  
Ethical Considerations
Compliance with ethical guidelines
This article was taken from a research project at the Islamic Azad University of Kermanshah Branch (Code: 19210 /0/00002) and was approved in 2021 with the code of ethics (IR.KUMS.REC.1400.637). In this study, all relevant ethics, including confidentiality and conscious satisfaction of the research participants, were considered.
Funding
This article was taken from a research project at the Islamic Azad University of Kermanshah Branch and the research deputy of this university was the financial support of this research.
Authors contributions
All authors contributed equally in preparing all parts of the research.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
We appreciate the research deputy of the Islamic Azad University of Kermanshah for their financial support as well as all the participants in this study.