Trust in Modern Medical Institution from the Perspective of COVID-19 Patients in Iran

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1. Introduction

COVID-19 originated in China and was confirmed and reported in Iran in late February 2020. While the Corona crisis appears to be a medical issue, it has unavoidable economic, cultural, political, and social consequences. These consequences affected all countries and had serious impacts in many fields (Bavel et al., 2020). Aside from the health and medical dimensions, some analysts believe that COVID-19 is an inherently social disease (Trout & Kleinman, 2020). Despite the disease's unavoidable social consequences, research on COVID-19 is primarily focused on health, hygiene, and biological issues. (Bruce & Yearley, 2014; Dzieciatkowski et al., 2020; Panyod et al., 2020; Ren, Zhang et al., 2020; Smereka et al., 2020)

Following the Corona crisis, many social scientists investigated the hidden dimensions of both social and mental health (Atalan, 2020; Moreno et al., 2020; Ornell et al., 2020; Talevi et al., 2020). Several stressed the importance of viewing epidemics and social responses from a sociological perspective. Compliance with or disregard of health protocols was one of these critical social dimensions. Will (2020) believed that focusing on social sciences would help manage the epidemic as a whole (Ferreira et al., 2020). Some researchers claimed that managing and controlling crises like COVID-19 in broader economic, cultural, social, and political contexts would be impossible without a focus on social science approaches. According to Monaghan (2020), regarding social dimensions, trust and security are two that must be examined. Humans seek psychological refuge and security when faced with dangers. As Giddens points out, 'expert systems' are one source of protection against the modern world's numerous dangers. (Giddens, 1996, pp.18–22) Research after COVID-19 focused on trust in various systems, including the media and policymakers. (Bargain & Aminjonov, 2020; Damghanian et al., 1399 [2020 A.D.]) However, the subject of this study is the modern medical institution, which is the most critical security institution against threats to human health. Medical sociologists will be interested in the level of trust in health care systems. They assert that 'late modernity' is a 'risk society,' stating:

In late modernity, there is a far more critical relationship between medicine and the lay populace, and that trust in medicine has to be increasingly won and maintained in the face of growing public awareness of the risks as well as the benefits of medicine and the limits of medical expertise (Gabe & Monaghan, 2013, p. 81).

However, while medical sociologists believe that gaining the public's trust in doctors is an important investment for the medical institution, they also believe that it can reduce an individual's independence and autonomy and allow for physical, emotional, and psychological dependence (Petersen & Bunton 1998, p. 105). Furthermore, medical sociologists distinguish between interpersonal trust (between patient and physician) and institutional trust (trust in medical organizations) (Rowe & Calnan, 2006). In his book, David Shore (2005 and 2007) discusses the importance of institutional trust in medical organizations and the reason for which it is important for the healthcare industry. (Shore, 2007, p. 3) Habermas (…., p. …, in Scambler, 2012) also attributes the decline in trust in physician-patient interactions to an imbalance in the rationalization of the 'system' and the rationalization of the 'life world', as well as the use of 'instrumental action' rather than 'communicative action'. Social theory serves as a lens, through which we can analyze the role of trust in health systems, write Meyer et al. (2008) in another study. They believe that current trust theories are flawed, especially because they fail to study 'trust' as a network of reciprocal relationships between individuals and systems. These theories also ignore the role of social factors (such as economic, social, age, and class) in trust. A critique of social theories of trust highlights the need for more empirical research in the multidimensionality of trust relationships (Meyer et al., 2008), which is the current study's viewpoint.

Patient's trust in the doctors and treatment personnel is an important component of trust in the medical institution. According to studies, patients’ trust in the doctor is directly associated with physical and mental health improvements (Shojaee & Abolhassani Niaraki, 1391 [2012 A.D.]; Cunningham, 2009). Furthermore, the patient's trust in a doctor will result in compliance with his/her order (Safran et al., 2002). Furthermore, if patients cannot trust the doctor or, more precisely, the doctor's position, the risks that threaten their health as a result of their refusal to listen to the doctor's recommendations generate ontological unease (Ghafari Nasab et al., 1396 [2018 A.D.]).

Several studies have focused on the patient-doctor interaction, particularly trust, in recent years (Baker & Waston, 2015; Peltola et al., 2018; Alpers, 2018; Skirbekk et al., 2011 and Shafati & Zahedi, 1393 [2014 A.D.]). In one of the most comprehensive studies, 54 articles related to patients' trust in doctors were examined and analyzed using a meta-composite qualitative method. Based on the findings of this study, improving the relationship between the patient and the doctor requires the provision of various social and professional conditions and contexts, including treatment management (improving equality of access and quality opportunities for all), learning treatment (informative training and strengthening the perceptive and human skills of doctors and treatment staff), and treatment environment management (training in communication skills, empathy with patients, and distancing from the authoritarian position for all medical staff) (Safaei et al., 1401 [2021 A.D.]).

Contrary to the fact that numerous studies have explored the interaction between doctor and patient and the trust between them at the micro level, Iranian academics have paid less attention to the issue of patients' trust in the medical institution as a whole. Javaheri (1393 [2014 A.D.]), for example, has investigated faith in Iranian medical institutions. She believes that by making the medical institution more transparent, trust can be strengthened. Using sociological theory to analyze medical transparency, she believes that achieving complete transparency will necessitate a multifaceted transformation of society's structural mechanisms, specifically the external and internal environments of medical institution (Javaheri, 1393 [2014 A.D.]). Javaheri’s research, although performed before the pandemic, pertains to the current study because it assesses institutional medical status and institutional trust. There is little research on public trust in the formal health system in Iran, highlighting the current study's importance. The current issue becomes important when a crisis like Corona redefines established assumptions in a wide variety of institutions and areas of thought and action, including trust in medicine.

The fatal COVID-19 virus is used in this article as an example of 'Interruptions in Everyday Life' as defined by Peter Berger and Thomas Luckmann (1991, p. 38) and 'Fateful Moments' as defined by Anthony Giddens (1996, p. 109). Whether the Coronavirus is natural or man-made (or Man-Made Disasters, as described by Ulrich Beck), it has prompted personal and social rethinking. Given the threat to human health, it is natural to rethink medical institution. Given this, the research problem consists of whether COVID-19 patients' trust in medical institution in Iran has been harmed or restored. In order to discover an answer to this dilemma, it is necessary to investigate the way in which Iranian COVID-19 patients perceive modern medical institution. In this regard, the following questions are considered: 1. How do Iranian COVID-19 patients perceive modern medical science. 2. How do COVID-19 patients in Iran perceive the hospital environment? 3. What is the attitude of Iranian COVID-19 patients towards doctors and medical personnel? 4. Given the COVID-19 situation, have patients with Corona in Iran chosen alternatives to modern medical institutions? If so, which alternatives?

2. Theoretical Considerations
3. 1. Institutional Trust

Theories are not the cornerstone of the current investigation because it is a qualitative study. However, the theories developed in the field of institutional trust have prompted scholars to carry out this research. As a result, in this section, we will look at institutional trust theories. According to the theories mentioned, citizens' trust in any institution is the result of its proper operation. Citizens' evaluations of an institution's performance constitute the basis of their trust in it. People will put their trust in institutions that are efficient and effective (Rothstein & Stolle, 2002). According to Giddens (2013, p. 26),

All disembedding mechanisms, both symbolic tokens and expert systems, depend upon trust. Trust is therefore involved in a fundamental way with the institutions of modernity. Trust here is vested not in individuals, but in abstract capacities. Anyone who uses monetary tokens does so on the presumption that others, whom she or he never meets, honour their value.

Additionally, Giddens distinguishes two types of trust: interpersonal trust and institutional trust (abstract systems). When institutional trust exists, there is no need to confront system officials. He believes, however, that non-specialist actors frequently come into contact with systemic officials, to which he refers as 'access points' (Giddens, 2013, pp. 90–91). He views trust in modern institutions as an abstract concept. Giddens believes that the nature of modern institutions is inextricably linked to the mechanisms of trust in abstract and specialised systems, and thus, he considers both structure and agency to play a role in institutional trust. According to him, “Trust, in short, is a form of faith... There is a pragmatic element in faith, based upon the experience that such systems generally work as they are supposed to do” (Giddens 2013, p. 27). In this regard, his example is instructive;

I have no particular fear of going upstairs in the dwelling, even though I know that in principle, the structure might collapse. I know very little about the codes of knowledge used by the architect and the builder in the design and construction of the home, but I nonetheless have "faith" in what they have done (Giddens 2013, p. 27).

Ulrich Beck (2013, in Bruce & Yearly, 2014, p. 263) is particularly interested in the nature of scientific experts. Beck asserts that science, too, faces 'reflexive challenges'. He argues that natural scientists cannot make the full claim of unmatched knowledge any longer, and that the public is sceptical of science's claim.

Putnam argues that trust is essential to social capital. He claims that trust promotes collaboration, and that a society's level of trust promotes collaboration. Cooperation also builds trust. Trust requires predicting the behavior of an independent actor. Individuals place their trust in one another when it comes to knowledge and predictions about their mood, potential choices, and abilities. This prediction holds true in small communities, where sincere trust is based on close acquaintance with the individual, but not in large and complex communities, where more impersonal and indirect trust is required (Putnam, 2003, pp. 184–85).

Lehman and Sztompka (2001, p. 51) believe that trust can only exist between humans and not between natural phenomena. In fact, trusting those objects implicitly trusts man-made phenomena and thus their designers and creators. Institutional and organizational trust, in his opinion, is one of the most abstract.

3. Methodological Considerations

The current qualitative study intends to evaluate Coronavirus patients' attitudes towards modern medical institution, specifically the way in which they trust this institution.

Thematic analysis is a specific method that has been used in research. In this study, Braun and Clarke's thematic analysis method was used to analyze the data. This type of thematic analysis has six stages, as follows: 1. Handwritten notes were read out. 2. The initial codes (concepts) and sub-themes were deducted from the sentences 3. The main themes were established 4. Themes were re-examined and modified as needed. 5. Their relationship was analyzed. 6. Finally, the thematic analysis report was obtained. It should be noted that in the current research, to ensure the validity of the analyses, two authors independently coded the primary and secondary data, and the research team double-checked the driven themes.

The study's statistical population consists of COVID-19 patients infected between the virus's Iranian outbreak and September 2020. Purposive sampling was used to select the 21 patients. It should be noted that all participants had recovered at the time of the interview. Two criteria were employed to pick the sample: the people's degree of education, ranging from high school to doctorate, and the severity of their sickness. In terms of disease severity, COVID-19 was classified into two levels: severe and mild. The patient's quasi-death condition was classified as severe COVID-19, whereas mild COVID-19 was characterized as a condition that is not fatal, but requires medical attention. It should also be mentioned that the patients vary in age and gender. (Table 1 illustrates the participants' biographical information).

It should be noted that semi-structured interviews were conducted with the participants. Interviews took place in the summer of 2020. Due to the study's qualitative nature and the coding process' interactive nature, more interviews were conducted in autumn 2020 to ensure data saturation. The interview questions were not theoretically written. Members of the research team, rather, prepared them. Several experts in the field of medical sociology were engaged to ensure the validity and reliability of the interview questions. In this regard, several exploratory interviews were conducted in order for the researchers to be able to reach suitable and accurate questions. Furthermore, the data was analyzed after each interview, and the questions were changed or revised if needed based on the analysis.

3. 1. Ethical Consideration

During the current study, the researchers did their best to adhere to the ethical requirements. All of these ethical points were noticed during data collection and interviews. Interviewees' names, surnames, and other personal information are kept private. Before beginning the interview, the overall topic of the interview and the researcher's aim were discussed with the interviewees. In addition, the participants were informed about the average length of the interview, and that they may exit the interview at any time if they do not want to continue. The interviewees' voices were recorded when their permission was obtained. Finally, the participants took part in the interview freely and without obligation.

3. 2. Research Limitations

Due to the rapid spread of the COVID-19 disease and according to health care, face-to-face interviews were not permitted at the time of the interviews; the researchers therefore had to substitute them with telephone interviews. Another restriction was the lack of a qualitative research that has studied trust in a modern medical institution as a whole. This problem has made it difficult for scholars to draw conclusions.

4. Findings

The thematic analysis of the initial codes revealed three fundamental axes based on the modern medical institution; these axes are as follows: 'medical science and expertise', 'hospital environment,' and 'medical staff. Following that, we will look at the findings for each of these axes. In addition, in this section, we will look at the findings connected to modern medical institution alternatives.

4. 1. The Perspective of COVID-19 Patients on Medical Science

The first axis that was address in this research was “medical science and expertise.” During  the interviews, patients debated medical science's strengths and weaknesses. Table 2 categorizes these strengths and weaknesses into two main themes: 'sources of trust' and 'sources of distrust' in medicine. Below are the major themes, sub-themes, and concept codes:

The data from the interviews revealed that Coronavirus patients' perceptions of medical science can be divided into two categories: ‘medical science's poor performance’ and ‘lack of a holistic approach in medical science’. Concerning poor performance, many patients cited medical science's inability to treat COVID -19:

I think at this point, the man realised that he was very weak... despite the advances in medical science, I realised that nothing came of it. In my opinion, the whole medical science of the world is weak and the only solution is quarantine, says the 8th participant (Participant 8).

Some participants related medical science's inability with humanity's weakness in the face of God's power (participant 16). Other patients refer to their unsuccessful medical experiences diagnosing and treating other diseases such as influenza (participants 5, 9) and AIDS (participants 6 and 1) to describe medical deficiencies. When asked how much hope there is for developing a vaccine to control the COVID-19, participant 5 stated: 

If it was supposed to be found so quickly, I believe it would be. I believe they won't be able to find the vaccine for at least the next year or two. For example, they still couldn't cure influenza, and so on.

Disappointment with the side effects of chemical drugs was another shortcoming of modern science, which has gained semantic dominance. Numerous patients have compared chemical medications to herbal remedies.

Mostly traditional medicine helped us, and hospital medicine was not so good. The pills just ruined my digestion to the point where I couldn't eat anything for the last five days, and the only thing I could eat was honey and nigella (Participant 13).

Contradictions between experts and trial and error on patients 'was another concept code that was repeated. Conflicting expert claims in the media and medical community reached a zenith during the COVID-19 outbreak. Although some patients ignored these problems by referring to the trial and error procedure of finding and treating the Coronavirus, others expressed confusion and a negative sense of being Guinea pigs' (participant 7). Participant 9 described the problem as follows:

Every time they say something different, I feel that they do not know what to do yet...

This participant's next sentence demonstrates his scepticism about the power of medical science:

I'm not sure if they do it because the virus is unknown, or because their diagnoses can be poor.

Giddens (1996, p. 121) has also considered the contradictions between experts and the difficulties inherent in making the correct diagnosis in medical science. He asserts: "In the face of such complexity, it is not surprising that some people withdraw trust from virtually all medical practitioners, perhaps consulting them only in times of desperation". David Shore (2005, p. 56) also views the media as a prominent source of conflicting medical advice.

As mentioned in Table 2, the other sub-theme within the main theme of the source of distrust is 'lack of holistic attitude,' which is comprised of two concept codes: 'lack of attention to traditional and complementary medicine' and 'lack of attention to mental health.' In this regard, Participant 1 stated:

Modern medicine rejects traditional medicine. If these two come together, they will get better and better results. Concerning the facilities of modern medicine, it is strong in diagnosis, whereas traditional medicine can be used in treatment.

Due to the prevalence of COVID-19 and the scientific limitations of modern medicine in treating this disease, it appears as though some alternatives, such as traditional medicine, have gained public attention. Additionally, Giddens (1996, p. 121) believes that in an age of reflexive modernity: "there are many practitioners of alternative medicine -- some of whom are now taken much more seriously by orthodox medical specialists than used to be the case -- who dispute the more mainline positions". Regarding ignoring the patients' tempers, participant 18 stated:

The patient has not been told which temperaments caused the disease in modern medical science... before the time of the Coronavirus, modern medical science had these defects, and the pandemic confirmed these deficiencies.

She also compares traditional and modern medicine in terms of the aforementioned ignorance, emphasizing that traditional medicine places a greater emphasis on the patient's temperament than modern medicine does.

In contrast, under the main theme of 'source of trust,' some patients provided rational justifications for trusting the medical institution by emphasizing the capabilities of modern medical science, both in prior experiences and in the fight against the Coronavirus. For example, participant 12 described her successful prior experiences;

I had back surgery and I am very satisfied with it; I saw modern medicine as a positive institution and it remains so in my mind.

Participant 4 described medical science's performance against the recent pandemic virus as follows:

I think it was good. I mean because the disease is unknown, using the antibiotic drugs and these things were also beneficial... they worked well to the extent that it was possible for them to do so.

According to some, modern medical science's advantage is in 'diagnosing diseases' (participants 1 and 4). Others discussed some of medical science's potential capabilities:

Except for cancer, almost all diseases have now been cured... I believe this (COVID-19) will also be cured soon (Participant 7).

Despite their criticisms of modern medicine's poor performance in treating the disease, some noted that chemical medicines aided in the healing process of the Coronavirus’s patients.

I trusted medical science before, and now I have the same opinion... my parents' condition was very bad, and we took them to the hospital, then we saw the effect of it, and they got better by taking the medicines, but as I said, they had effects to some extent... (Participant 11).

Furthermore, the sub-theme of 'being  hopeful about the future of medical science' refers to a level of patients' trust in modern medical institution that is unrelated to how they are treated during the course of their disease, but rather is based on the future and medical science's ability to monitor potential risks. And, according to Giddens (1996, p. 164), this capability is one of the most important aspects of modernity reflection. Several interviewees expressed a lack of hope for modern medicine during their illness, but in the face of the security threat and the impact of the COVID-19 virus on their personal and social lives, they believe that it is possible to develop a medication or vaccine for COVID-19 and assign an effective role to medical institution. In this regard, Participant 3 attributes her hope for the eradication of Coronavirus to 'medical staff' and the 'global medical community.' Belief in the capacity of humans to solve scientific problems falls under the same category:

I believe that man can achieve much higher things than this and I believe that this is a simple task for humans (Participant 10).

 While the theme of 'being hopeful about the future of medical science' was prevalent among the participants, it should be noted that the majority of participants disagree with this theme or attribute the possibility of developing a vaccine through the will of God or by supernatural powers, rather than the power of medicine. For example, participant 1 stated:

Given the multifaceted nature of COVID-19, it is unlikely that doctors will be able to Develop a vaccine, and I believe this disease will go away only if Allah wills.

4. 2. COVID-19 Patients' Perspectives on the Hospital Environment

In their explanations of the modern medical institution's performance, several participants noted the disadvantages and advantages of the hospital environment. Furthermore, some participants did not receive hospital care during their sickness and hence did not provide particular feedback in this area.

As mentioned in Table 3, the sub-theme 'The advantages of hospitalization' is one of the factors that contribute to modern medical institution's trustworthiness:

When I went to the hospital, my mood changed... the medications worked, and I felt better. Then I wondered why I hadn't gone to the hospital sooner (Participant 10).

He also expressed his gratitude to the volunteers who assisted in the hospital. In this regard, participant 20 stated,

I thought to myself, if I go to the hospital, there is a doctor, but if I stay at home, there is no doctor.

On the other hand, the sub-themes 'Fear of going to the hospital' and 'Disadvantages of hospital care for COVID-19' were obtained:

The doctor advised me to be hospitalised. He also mentioned that it  might be difficult for me to breathe and that my lungs would need to be repaired; I said no, I can't... Both because of my baby and because of the high hospital costs.... (Participant 6)

The fourth participant's sentences further explain the mentioned sub-theme:

I was in the hospital for a week and was discharged with a fever... but when I saw my baby, my condition improved, and I became mentally much better. Nurses don't get too close and don't talk to you much in the hospital, which indicates that the situation isn't mentally healthy, so it made our recovery process at home easier.

Participant 12 expressed her distrust of the hospital environment as a result of the 'high rate of hospital mortality' and 'excessive usage of disinfectants in hospitals'.

On the other hand, some COVID-19 patients emphasise the psychological component of hospital phobia as a source of distrust in the medical institution. 'I am afraid to go to the hospital and suffer from hospital phobia, so I cannot easily accept the hospital,' participant 18 stated. Although Participant 10 expressed satisfaction with his hospitalization, he spoke of developing a hospital phobia as a result of those around him.

4. 3. COVID-19 Patients' Perspectives on Medical Personnel

As illustrated in Table 4, the sub-themes 'the medical staff's sacrifice and hard work' and 'Iran's availability of highly qualified and experienced physicians' are the sources of medical staff trust. Additionally, some COVID-19 patients who had never been to a hospital or had little contact with doctors spoke of the treatment staff's sacrifice. Thus, the media may be considered effective in fostering this belief and thereby increasing trust in medical personnel.

I give Iranian doctors a score of 100... Because they did their best for the patients... the heavy clothes they wore is enough to say that they did their best... although there is some debate about the specialty and science of medicine (Participant 19).

Participant 13 distinguished the scientific aspects from the efforts of doctors in dealing with COVID-19 as follows:

It varies depending on whether you are discussing the function of our doctors or the scientific aspect... They were terrible and incapacitated scientifically, but our doctors' function was extraordinary, and they worked harder than they could.

Additionally, some mentioned the expertise and experience of Iranian doctors, which strengthen Iran's medical system. When asked about the ability of Iranian doctors to deal with COVID-19, Participant 16 responded as follows:

Yes, I believe they will be able to solve it; it is not impossible... In general, I believe our country is strong.

The following sub-themes emerge from the data and can be viewed as the sources of distrust in medical staff: 'medical personnel's body-centred attitude', 'doctors' and physicians' insufficient scientific knowledge', and 'medical personnel with negative personality traits'. Participant 14 expressed his displeasure with doctors' disregard for people's mental health, stating:

Physicians need to focus more on the patient's mental health and what happens in their thoughts later.

This sub-theme (lack of attention to patients' mental health) was expressed by participants about the general atmosphere of medical science in the world, but it seemed necessary to separate the field of medical science (structure) from the field of agency (medical staff). As a result, the aforementioned sub-theme was investigated separately in these two areas.

Furthermore, under the sub-theme of 'Doctors' and physicians' insufficient scientific knowledge,' some participants expressed their dissatisfaction with poor diagnoses or frequent medication changes by doctors:

Medically and technically,... I almost feel like they know as much as I know, and the only difference between us was that they understood more about the CT scan and I understood less,' (Participant 6).

One of the participants mentioned that some of the doctors were extremely concerned with money:

We have doctors who have a lot of experience. They are very concerned with money... but they are excellent in terms of medical science (Participant 12).

Doctors' extreme fear of COVID-19 was also mentioned as one of the medical personnel’s negative characteristics by participants:

As a doctor, you see a lot of deaths, which increases your fears... my friend's sister's daughter is a doctor, and she is terrified of what it's like in the hospital (Participant 14).

According to the findings reported in tables 2, 3, and 4, it appears that the respondents' trust in modern medical institution has improved in one aspect while being weakened in others. Indeed, it appears that the Coronavirus patients interviewed have strengthened their trust in medical personnel. While their trust in medical science and the hospital environment has dwindled.

In this regard, Ulrich Beck believes that reflexivity has scrutinised scientific knowledge in the risky modern world (including medical expertise). Thus, science and expertise have become less precise and frequently fragmented, resulting in a decline in the authority of specialised knowledge (Bruce & Yearley, 2014, p. 18).

It should also be noted that there is an obvious difference in attitudes toward 'medical science and expertise' between participants with a university degree and those with little or no academic education. The power of medical science is further threatened by highly educated participants. Participants 11, 12, 19, and 20 rely more on the power of science. Educated participants 21, 8, 2, 5, 5, 6, 7, 17, 16, on the other hand, emphasize the 'lack of holistic attitude' and 'insufficient performance' of medical science. They also criticize the 'hospital environment' and the 'medical staff'. The results of this analysis are compatible with Giddens' theory of 'increased reflexivity,' which according to Seidman (2013, p. 144) asserts:

This same reflexivity, however, opens the possibility that rational or discursively derived agreements about rules might become the highest principle of social legitimation. Democratization and autonomy are accordingly implicit in the conditions of late modernity. On the other hand, heightened levels of institutional reflexivity introduce new social risks and dangers. For example, increased reflexivity means heightened contestation over knowledge claims and, therefore, ironically, less certitude (Giddens, … , p.   , in Seidman, 2013, p. 144).

This description suggests a connection between higher education and 'enhanced reflexivity.' Indeed, it appears as though those with a higher academic education are more aware of the limitations of modern science, and thus their trust in medical science has diminished, particularly in the critical situation of COVID-19.

4. 4. COVID-19 Patients' Perspectives on Modern Medical Institution Alternatives

Doubts about the modern medical institution's credibility in post-COVID-19 reflexivity appear to be a threat to modern man's existential security, raising the question of what resources could replace the modern medical institution as a source of security or ‘protective cocoon’ as COVID-19 risk increase. The answer to this question can be deduced from the statements made by the study's participants. Their responses are summarized in the table below under the main theme 'Alternatives to the Medical Institution in Fostering a Sense of Security and related sub-themes.

4. 4. 1. Mental Alternatives

One of the sources of security that is emphasised in psychological approaches (Dockray & Steptoe, 2010) is positive thinking and maintaining a hopeful mood, which are sometimes induced by individuals and sometimes by those around them, according to participant 11:

One of my friends, who constantly hugged others, did not get the COVID-19 because she has high morale and did not get the virus at all. She is very optimistic.

When asked if she hoped to recover during her illness, participant 8 replied, "Yes, I do, because, as I previously stated, I have high confidence".

The mental alternatives mentioned by interviewees bear a strong resemblance to some of Berger's 'transcendent signs,' particularly when Burger speaks of the transcendent sign of 'hope.' He believes that the greatest hope exists in situations in which the individual attending to death demonstrates courage and fearlessness. Hope is a desperate attempt to forget and avoid death. By refusing to die, man demonstrates his faith in the other world (Berger, 2011, p. 74).

4. 4. 2. Natural Alternatives

Some participants cited the natural process of disease as a source of security; for example, participant 8, who had little hope that the medical community would eradicate the virus, stated

There is a coronavirus, and it will not go away... It's similar to the flu. Every epidemic lasts a year to a year and a half, and the condition has been the same throughout human history. It has two or three mutations before weakening.

4. 4. 3. Traditional Medical Alternatives

As previously stated, several participants used traditional medicine to treat themselves during the COVID-19 disease, and they specifically viewed complementary medicine as a superior alternative to modern medical institution (such as participants 13 and 18). Interviewee 6 explained the way in which herbal medicines aided in his treatment:

To my mind, I am significantly better with these herbal remedies... I believe that these medications helped me psychologically as well. Whenever I took these herbal remedies, they calmed me. However, when I took the large pills, I only experienced nausea for three hours.

Additionally, some interviewees express hope for the eradication of the disease through complementary or traditional medicine (participants 12 and 20), indicating the importance of traditional medical alternatives as a source of security for patients.

4. 4. 4. Physical Alternatives

Some individuals also relied on their physical abilities and the absence of underlying diseases to ensure their survival in the critical conditions of COVID-19. For example, participant 15 mentioned her 'excellent physical strength,' while participant 19 discussed the effect of the physical recovery on his sense of security and hope.

When I felt better, my fever subsided, and I didn't cough, I realised that, yes, I was hopeful.

4.4.5. Immaterial Alternatives

These immaterial alternatives provide patients with a sense of security both during and after illness. The following examples substantiate this assertion, as put by participant 19:

I walked to the edge of the abyss, but one hand stopped me... I discovered that if Allah wants me to stay, I will... I might have died if Allah and the Ahl al-Bayt[1] had not helped me, but Allah willed it, and I returned...

He views his spiritual experience during his illness as a source of hope for people worldwide who are afflicted with this disease (COVID-19). Additionally, some participants believe that if God wills, the medical staff's efforts will be successful. In this regard, participant 20 stated:

We believe in medical science, but our greatest faith is in Allah. At the same time, doctors, their knowledge, and their abilities are critical for disease treatment... Allah is the first and last. We have complete faith in Allah.

In a different light, participant 15, by announcing the demise of medical science, alludes to God's assistance in establishing a protective-security cocoon:

I only have faith in Allah. I beseech Allah to wipe out this disease, and I beseech the Imam al- Asr[2] to come and save us.

According to Berger, the COVID-19 disease, with its death-like symptoms, creates a 'marginal situation' that 'reveals the innate precariousness of all social worlds' and jeopardises social order's fundamental assumptions. In such circumstances, only religion can serve as a 'sacred canopy', legitimizing and giving meaning to the existing social order (Berger, 1967, pp. 32–33). According to this description, COVID-19 appears to have shifted the patients from one protective cocoon to another by weakening the modern medical institution (in some ways), as the primary source of security against health threats (Giddens, 1996, p. 126). As illustrated in the tables (above), one of the most serious competitors of modern medical institution is traditional medicine or treatments. Additionally, psychological factors such as positive thinking have been shown to notably contribute to some patients developing a sense of security.

Giddens believes that one of the traditional, religious, and fundamentalist sources' missions is to mitigate the dangers of modernity and install a sense of security in their adherents. He refers to the concept of fatalism[3] as a source of security. According to Giddens (1996, p. 129), "the psychological security that conceptions of fate can offer is largely foreclosed". 

According to him, the 'fatalistic ethos' emerges as a public response to probable risks in non-religious communities, particularly when confronted with dangers beyond our control. In other words, when members of society tire of the exaggerated sense of danger, they decide to abandon everything and live according to the dictum 'whatever will be, will be' (Giddens, 1996, p. 131). There are also parallels between the data obtained and Giddens' theory in this section. Certain participants appear to be seeking a form of release from the COVID-19's 'risky climate,' which appears to be distinct from seeking materially protective cocoons. Indeed, they submit to fate, destiny, and whatever is assigned to them. For instance, participant 16 described the quarantine and its association with illness as follows:

There is no doubt about it. If it's supposed to be, we get it, we get it.

In this regard, participant 1 added:

I'm not sure why people are afraid, but I don't think it's too scary... I surrendered to Allah.

In contrast to 'fatalism' in non-religious communities, the data gathered from the present study's interviewees reflects the concept of 'religious fatalism' or 'spiritual fatalism.' In contrast to pure destinyism, this form of fatalism acts actively and manifests itself in acts such as 'trusting in God', 'praying and vowing and worshiping', and 'appealing to the righteous Imams and servants of God'.

5. Conclusion

It seems that people's trust or lack of trust in society's institutions has a significant impact on their performance and efficiency. Furthermore, it appears that the risk of the Coronavirus provides a fantastic platform for researching the understanding of individuals, particularly COVID-19 patients, about the modern medical institution. The purpose of this study was to investigate the trust that Iranian COVID-19 patients have in modern medical institution. To investigate this problem, the perspectives of Iranian COVID-19 patients in relation to modern medical institution should be studied. However, it should be noted that the current study is a qualitative study, and the researchers do not claim that the findings are generalizable to all COVID-19 patients or all Iranian COVID-19 patients, and the results obtained are only related to the twenty-one patients studied in this research.

In order to investigate Iranian COVID-19 patients' perspectives towards modern medical institution, as well as their trust in this institution, an attempt was made to provide an appropriate categorisation of patients' perspectives on modern medical institution. As mentioned previously, data analysis revealed three major axes: 'Medical science and expertise,' 'Hospital environment,' and 'Medical personnel'. Twelve sub-themes also fall under these three axes, including: ' Medical science's strength', 'Being hopeful for medical science's future', 'Lack of holistic approach in medical science', 'Medical science's poor performance', 'Advantages of hospitalization', ‘Disadvantages of hospital care for COVID-19',' Fear of going to the hospital' , ‘Medical staff's sacrifice and hard work', 'Iran's availability of highly qualified and experienced physicians', 'Medical personnel's body-centred attitude', 'Doctors' and physicians' insufficient scientific knowledge ' and ' Medical personnel with negative personality traits ,' all of which are related to the two central themes of 'Source of trust' and 'Source of distrust.'

According to the findings, the semantic predominance of themes connected to the "origin of distrust" in the fields of "medical science and expertise" and "hospital environment" is greater than the other axis. In comparison, the data revealed that the notions of "sacrifice and hard work of the medical staff" and "availability of experienced doctors in Iran" are effective for developing the trust of Iranian patients in modern medical institution. In other words, the "Medical Personnel" axis comprises a greater number of trust-related items than the other two axes. Other relevant studies support this conclusion. For example, in a quantitative study, the trust of patients in Qazvin city in nurses as one of their medical personnel was evaluated as meaningful and acceptable (Nooripour Liavali et al., 1394 [2016 A.D.]).

In addition, it can be stated that the respondents' trust in modern medical institution has improved in one aspect while being weakened in others. Indeed, it appears that the COVID-19 patients interviewed have strengthened their trust in medical personnel. While their trust in medical science and the hospital environment has dwindled.

Furthermore, it appears that the expansion of COVID-19 has laid the groundwork for patients' scepticism about the authority of modern medical institution, based on the data. As a result, the COVID-19 patients polled for this study have begun to look at alternatives to the modern medical institution, specifically medical science and expertise. In such cases,' mental, immaterial,' 'natural,' 'physical,' and 'conventional therapeutic' alternatives can be helpful in giving persons at risk of the virus a sense of security. Meanwhile, as a notable response to the risks posed by the Corona crisis, the concept of "spiritual fatalism” was demonstrated, which is an important outcome in religious Iranian society. Although many related studies focus on the role of mental factors (Dockray & Steptoe, 2010), immaterial affairs (Soltan Mohammadi, 1400 [2021 A.D.]; Mardanian Dehkordi & Shahgholian, 1393 [2015 A.D.]), and traditional medicine (Eisenberg et al., 1998) as an alternative or supplement to modern medicine in the health process, examining these sources together and from the perspective of patients is considered one of the current research's achievements.

It should also be noted that the 'mediated experience' (Giddens, 1996, p. 84) and the important role of the media in highlighting some themes related to the modern medical institution are among the study's notable findings. Although participants have direct experience with COVID-19, it should not be overlooked that the media has an indirect impact on their attitudes. As previously stated, the impact of this issue can be seen in the sub-theme of the medical staff's sacrifice and hard work’.

Due to the numerous similarities between 'medical science and expertise' in many countries throughout the world, the findings of this study, regardless of Iran's social context, can serve as a point of reference for other cultures and countries, as well as a cautionary tale about the global role of 'medical science and expertise.' Conducting complementary research on the subject of current research can provide researchers and policymakers with more complete and comprehensive findings. It is advised, for example, to do study on how people trust traditional medicine or other alternative medicine and compare its place in people's perceptions with modern medicine

A loss of trust in the formal medical institution can have a plethora of negative consequences for a society. Avoiding formal medical institution is accompanied by alternatives, some of which are not supervised by any official institution, and the tendency of people to gravitate toward these alternative systems can be viewed as a threat to public health in the long run. Thus, it appears necessary to use the findings of this study and other similar studies to improve the efficiency and performance of the modern medical institution.

[1]. In Islamic tradition, Ahl al Bayt primarily refers to the family of the Islamic prophet Muhammad (PBUH).

[2]. The 12^th Imam of Shias, who, according to Islamic belief, will appear at the end of times to rid the world of evil and injustice.

[3]. Giddens believes that contrary to many people's beliefs, the concept of destiny has found a place in the modern world, he says "Yet notions of fate refuse to disappear altogether, and are found in uneasy combination with an outlook of the secular risk type and with attitudes of fatalism" (Giddens, 1996, p. 130).