
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-249
10.4103/jehp.jehp_694_23
Original Article
Modeling the structural equations of the corona anxiety level based on psychological hardness and physical activities in the treatment staff of Ilam Province with the mediator role of professional identity
Rezaei Shamseddin
Shams Morteza 1
Azizifar Akbar 2
Aibod Sehat 3
Gohari Ziba 4
Department of Physical Education, Ilam University, Ilam, Iran
1 Zoonotic Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
2 Department of Psycholinguistics, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
3 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
4 Master of Sports Management, Ilam University, Ilam, Iran
Address for correspondence: Mrs. Ziba Gohari, Department of Sports Science, Master of Sports Management, Ilam University, Ilam, Iran. E-mail: ziba.gohari1991@gmail.com
2024
29 7 2024
13 24919 5 2023
01 8 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

The increase in deaths due to COVID-19 has increased anxiety among the treatment staff. Therefore, the purpose of this research was to model the structural equations of the anxiety level of corona based on psychological hardness and physical activities in the treatment staff of Ilam province with the mediator role of professional identity.

MATERIALS AND METHODS:

Based on the purpose, the method of this research is applied and based on how to obtain the data it is descriptive–correlational. The statistical population of the research includes all the treatment staff of Ilam province, with the number of 1900 people who were selected using Morgan’s table, 320 people with the stratified sampling method as the sample. To collect the data, four standard questionnaires were used: Alipour et al. (2020) coronavirus anxiety questionnaire, Kiamarsi et al. (1998) psychological hardness, Baecke et al. (1982) physical activity, Hao et al. (2014) professional identity, and their validity and reliability were also confirmed. To analyze the data, from the indicators of descriptive statistics, Pearson’s correlation coefficient test and structural equation model method (SEM) were used using SPSS and Amos software.

RESULTS:

The results of the research showed that psychological hardness, physical activities, and professional identity have a significant and inverse effect on the anxiety caused by corona, and the mediator role of professional identity in the relationship between physical activities and corona anxiety was confirmed, but this role was not confirmed in the relationship between psychological hardness and corona anxiety.

CONCLUSION:

To reduce the anxiety of the coronavirus in the treatment staff, the managers of the health and treatment centers of Ilam province should pay special attention to the employees’ perceptions of psychological hardness, physical activities, and professional identity and provide them with the opportunity to create sports activities.

Corona anxiety
physical activities
professional identity
psychological hardness
treatment staff
==== Body
pmcIntroduction

Today, all organizations are in search of maximizing their performance, and for their growth and survival, they try to achieve rapid growth, more efficiency, continuous improvement, preparation for the future, flexibility, and privileged position through their resources. In the past, the resource of any organization includes money, places and equipment, and land; but today, human resources are considered the main source of creating value in organizations and as a competitive advantage and looking at it as a cost is outdated.[1] Health and treatment centers are not exempt from this rule, and the most basic effort of these organizations is to increase the health of their active and efficient human resources, especially the treatment staff as the main body for providing services to patients. As the powerful arms of the healthcare system, the treatment staff play a significant role in the development and progress of care, treatment, improvement, and promotion of people’s health and have a close and tight relationship with society, they bear the responsibility for the health and life of people and with patients, and they face various and sometimes incurable diseases.[2] The treatment staff consisting of doctors, nurses, paramedics, psychiatrists, operating room technicians, radiology, etc., are directly related to the health of communities. The profession of treatment staff is one of the jobs that, due to its special nature, has rotation and variety in working time, and they may work during the days of the week and at different hours of the day and night, or in long shifts in the hospital and at their workplace, and these conditions may increase their stress and anxiety.[3] The profession of treatment staff is one of the jobs that, due to its special nature, have rotation and variety in working time, and they may be busy working during the week and at different hours of the day or night, or they may work long shifts in the hospital and at their workplace. These conditions increase their stress and anxiety.[3]

In the last days of 2019, health and treatment centers noticed that people were suffering from a new type of lung disease, and the continuation of various researches led to the identification of a new type of coronavirus. Coronaviruses are a large family of viruses, of which seven species have been discovered to be transmitted to humans. Generally, coronaviruses first cause an infection in the respiratory ciliated mucus in the pharynx and nose, which show symptoms similar to a common cold.[4] Also, sometimes they may cause more serious diseases such as terminal bronchial infection and exacerbation of asthma, chronic bronchitis, and even lung infection in adults, the elderly, and people with a weak immune system.[5] After the increase in cases and global spread of this virus, on January 30, 2020, the World Health Organization announced the spread of the new coronavirus as the sixth cause of public health emergency worldwide which was a threat not only to China but also to all the countries of the world.[6] The COVID-19 disease originated from bats and then was transmitted to humans through an intermediary host in the Wuhan market. It has been concluded that the path of transmission and evolution of the disease of COVID-19 was from bats to anteaters (intermediate hosts) and then to humans.[7] On February 11, 2020, the World Health Organization chose the official name for the new coronavirus disease as Covid-19 (COVID-19) and, on the same day, changed the scientific name of the virus that causes this disease from 2019-nCoV to SARS-CoV-2.[6] According to global statistics, a mortality rate of 3.4% has been recorded for this disease[8]; however, the results of Wang et al.[9] (2020) research showed that the mortality rate was 2.84%. According to the results of Huang et al.[10] (2019) research, this rate was 15%. Wu et al.[11] (2020) reported this rate as 14%. In the study by Zhu et al.[12] (2020), the mortality rate was 33%. Guan et al.[13] (2020) reported that the mortality rate is 1.4%. According to the official data of the Chinese government, the mortality rate was 3.2%, and according to the published meta-analysis, this rate was 6.4%.[14] According to the official announcement of the Ministry of Health, Treatment and Medical Education, the number of deaths due to the corona disease in Iran so far is 146 thousand 290 people, of which about 1350 people are from Ilam province. This disease has a wide range of psychological and social effects on the society during its outbreak. At the individual level, people are likely to experience the fear of getting sick or a sense of powerlessness in facing the disease, and as a result, its prevalence can cause significant stress that may lead to adverse effects on people’s spiritual and psychological health. The symptoms of this virus are very different from mild to severe and include fever, cough, and difficulty breathing, and anxiety is a common symptom in patients with chronic respiratory disorders including corona disease.[1516] Therefore, anxiety is one of the most common mental disorders, which means an unpleasant and vague feeling of fear and anxiety of unknown origin in emergency situations, and corona anxiety is one of the psychological consequences of COVID-19 since it is unknown and creates cognitive ambiguity about it.[17] Fear of the unknown reduces the perception of safety in humans,[17] as well as the lack of scientific information about this disease intensifies this anxiety.[18] Anxiety is an unpleasant feeling that most often causes worry and apprehension that is associated with one or more physical factors such as heart palpitations, shortness of breath, and restlessness.[19] Anxiety is normal as an adaptive and necessary response to stress that prepares a person for an appropriate response when faced with danger.[20] Corona anxiety is defined as people’s worries about the coronavirus and its dangers. Coronavirus has quickly endangered the physical and mental health of different societies and has caused stress and anxiety among the people, in which long-term anxiety can be a threat to the public health of people, especially the treatment staff.[21] Every day, the treatment staff in the clinical environment witness the many sufferings and discomforts of others and special hospital situations such as the sickening and death of patients, insomnia, uncertainty, and disruption in interpersonal relationships, which increase tension and the vicious cycle of anxiety in them, and this anxiety has an effect on them. It affects other aspects of the life of the treatment staff and also affects their productivity and quality of work.[21] Due to the special conditions caused by the work environment, the treatment staff experience more stress and anxiety and may even transfer this stress and anxiety to their family and friends.[2] Coronavirus has quickly endangered the physical and mental health of different communities and has caused stress and anxiety among people, and this long-term anxiety can be a threat to the public health of people, especially the treatment staff.[18] Due to the special conditions caused by the work environment, the treatment staff experience more stress and anxiety and may even transfer this stress and anxiety to their family members and friends.[2] Also, the medical staff experience a lot of anxiety compared to other sections of the society due to the physical contact with the corona patients and considering that these people are on the front line of the fight against COVID-19, they are the first to be exposed to the virus and for this reason, and they suffer a lot of anxiety.[22] The results of Kahwazi research (2022) showed that the level of anxiety of the coronavirus is affected by psychological capital and spirituality.[23] The findings of the research of Akhlaghifard and Meraji (2021) showed that there is a positive and significant correlation between emotional disturbance and the level of anxiety of corona in the medical staff of Islamshahr.[21] According to the findings of Zhou et al.[24] study (2021), the increase in psychological capital has reduced the anxiety of Chinese women’s medical staff during the corona era. Wang et al.[25] (2020) have reported the level of depression, stress, and anxiety caused by the corona disease in China as moderate and severe.

One of the most basic needs of living beings, which may have received less attention, is the need for exercise and physical activities. Sports has a special place for most countries due to its positive social, cultural, and economic effects, as well as its undeniable role in the general health of societies.[18] Considering that the gift of machine life in today’s advanced societies for humans is immobility, physical weakness, mental and emotional problems, etc., the importance of exercise in various matters of individual and social human life becomes more and more visible.[26] The results of various researches show that the main factors affecting a healthy lifestyle and prevention of COVID-19 include exercise and physical activities with moderate intensity, proper nutrition, stress control, and social distancing.[27] Neiman and Nehlsen (1994) have described the relationship between the risk of upper respiratory tract infections (URTI) and the amount of physical activities as a “J-shaped” curve [Figure 1]. This means that by increasing the amount of exercise, the risk of infection decreases.[28]

Figure 1 J-curve model of the relationship between exercise load and the risk of URTI

Scientific experiences show that when people are anxious, work and physical activities can take their mind away from the source of stress and anxiety and may moderate stress by entertaining people.[18] The results of various researches show that there is a positive and significant relationship between the amount of physical activities and the physical and mental health of people, and physical activities can reduce the level of stress and improve the symptoms of anxiety and depression by improving resilience and separating the person from the stressful factor. However, the effect of physical activities on improving mood and mental disorders requires sufficient time and regular and continuous exercise.[18] It is clear that mental and psychological treatments, drugs, and the healthcare system alone cannot reduce the psychological problems of the treatment staff; therefore, physical activities and sports can be one of the effective ways to improve mental problems.[27] Physical activities in critical situations such as the spread of the coronavirus, where there is still no suitable medicine or definitive vaccine for prevention, are related to the level of stress, anxiety, depression, and mental health of societies.[29] Hosseinpour and Godarzi (2022) reported that doing sports activities will reduce their anxiety due to the predominance of its physiological aspect, whether it is according to the desire of the treatment staff or not.[29] Momtazbakhsh et al.[30] (2021) stated that performing physical activities such as walking can be recommended as a useful and uncomplicated method to reduce patients’ anxiety along with drug treatments. The results of Gorbanzadeh and Lotfi research (2017) showed that physical activities and exercise as a non-drug treatment can improve mental skills.[31] The research findings of Lesser and Nienhuis (2020) in Canada showed that people who have more physical activities during the corona era have less anxiety and a better level of well-being.[32] The results of Zhao et al.[33] (2020) research in China showed that people who have more physical activities have a better emotional state. Brand, Timme, and Nosrat[34] (2020) conducted research in 18 countries of the world (statistical sample of 13,696 people) and showed that there is a significant positive relationship between the amount of sports activities and mood changes of people; this means that people’s mood was affected by the amount of physical activities.

One of the important factors related to psychological abilities and mental health in the treatment staff is psychological hardness. Psychological hardness allows people to be equipped with effective coping skills and to gain more adaptability, show less vulnerability to difficult situations, and feel empowered.[35] Kobasa introduces psychological hardness as one of the factors that influence the response to stress, which indicates an effective strategy to cope with stress and facilitates the response to stressful situations.[36] Psychological hardness is one of the main personality factors that is conceptualized to understand emotion, motivation, and behavior and is a combination of positive attitudes that provide the motivation, courage, and ability necessary to achieve growth and development and turn environmental tensions into development opportunities.[37] Also, psychological hardness is defined as the fact that a person is committed to what he does and dedicates himself to the goal (commitment), has a sense of mastery over the situation (control), and considers the challenges and limitations of life as an opportunity for growth and development (Defiance).[38] In fact, it can be said that people with favorable levels of psychological hardness, due to the existence of fighting qualities and self-expression and endurance in the face of stressful environmental events, are less likely to suffer physical and mental injuries; therefore, the importance and necessity of strengthening psychological hardness in different societies are revealed. Researches indicate the role of psychological hardness in reducing anxiety of corona in students and improving mental well-being in nurses.[3637] Aybek, Yetim, and Aybek (2019) believe that athletes with more psychological hardness have higher self-esteem, have less stress and anxiety in sports competitions, and see competition as a favorable, controllable, and challenging situation.[39] The research findings of Sheikhesmeili et al.[40] (2020) showed that psychological hardness has an effect on the sleep quality of the elderly. Khoraminejad and Jahan[41] (2020) stated that psychological hardness has an effect on the self-esteem and perfectionism of athletes. The research findings of Yousefi Afrashteh, Golmohammadi, and Tamjidi[42] (2021) showed that psychological hardness has a significant effect on death anxiety and ambiguity tolerance of MS patients.

Identity is a part of self-understanding that is determined by the person’s constant awareness that a person is separate and distinct from others and is the most important factor in proving one’s territory.[43] It is not possible to imagine a profession without a professional identity, but there is a possibility that people in any job and profession are not able to integrate and combine themselves with the professional values and obligations of their job and therefore cannot adhere to the essence of their identity.[2] A sense of identity with a profession requires continued presence in that profession and a high sense of responsibility toward it.[43] Valizadeh and Ghorbani[44] (2015) stated that people who are deeply involved in their profession consider their profession as an important part of their personal identity and devote most of their interests to it. Having a positive professional identity, in addition to being an important factor in increasing self-confidence, also causes a feeling of belonging to the profession and establishing interpersonal communication. Professional identity allows people to be part of specialized groups and show a sense of belonging to their professional world. Professional identity plays an important role in shaping self-image. The more people communicate with a certain group, the more this group plays a role in shaping how people feel about themselves.[43] The basis of professional identity formation is providing altruistic services to the society, having a distinguished body of knowledge, independent and authoritative performance and decision-making, compliance with ethical codes, commitment to lifelong learning, and issuing an official certificate at the end of the training course to the students of that profession.[45] The professional identity of the treatment staff is more than providing healthcare services. In fact, the professional identity of the treatment staff provides a framework for them regarding “how to be,” “how to act,” and “how to understand” their work and role in society.[2] The formation of the therapist’s professional identity is an ongoing process of personal and professional interaction to answer the question of how to be a good therapist. To achieve a positive professional identity, medical staff needs to improve their public image and gain a stronger position in healthcare organizations by increasing their presence in scientific societies.[44] The research findings of Valizadeh and Ghorbani[44] (2015) showed that a positive professional identity causes the personal, social, and professional development of the treatment staff. Karimi Johani et al.[46] (2020) stated that the professional identity of medical workers is progressing over time and compared to the past and to achieve a progressive professional identity, education, and research in this field should be developed at the university level.

The most important group in the field of controlling the COVID-19 crisis in Iran is the treatment staff, who have played a key role in breaking the transmission chain since the beginning of the epidemic of this disease (such as informing the public, providing sanitary supplies, organizing laws such as quarantine and prevention of transmission of false information in the field of disease). In addition to breaking the chain of transmission, maintaining peace and controlling mental crises of oneself and society is also one of the main duties of the treatment staff.[21] Reviewing and summarizing the background of the research shows that the corona epidemic has created serious threats to the life and physical health of people and has also caused severe psychological problems such as stress, depression, anxiety, and tension in the general population and especially in the group of healthcare employees. Considering the extent of the spread of COVID-19 in Iran and its death rate, treatment staff is more exposed to psychological disorders and anxiety due to being on the front line of dealing with this disease. Considering the importance of knowing the psychological state of the treatment staff, it is necessary to inform the institutions in charge of their psychological state; because the overall health and peace of every society depend on the mental health of the treatment staff. Therefore, it is important and necessary to pay attention to the psychological health of these people who are defenders of the health of society. Based on this, it is very important to identify the factors that can affect the anxiety caused by the coronavirus. Therefore, the present study was conducted with the aim of modeling the structural equations of the level of anxiety of corona based on psychological hardness and physical activities in the treatment staff of Ilam province with the mediator role of professional identity [Figure 2].

Figure 2 Conceptual model of research

Materials and Methods

Study design and setting

Based on the purpose, the method of this research is applied, and based on how to obtain the data, it is descriptive–correlational. The study was carried out in the field and cross-sectionally in the fall and winter of 2021. which is done in the city of Ilam, a province in the west of Iran.

Study participants and sampling

The size of the statistical population of the research includes the entire medical staff (doctors, nurses, paramedics, operating room technicians, anesthesiologists, radiologists, etc.) of Ilam province, which is, according to the report of Ilam University of Medical Sciences, equal to 1900 individuals. The size of the statistical sample was also determined using Morgan’s table of 320 people, and the relative stratified and then random sampling methods were used according to Table 1.

Table 1 Number of population and statistical sample by the cities of Ilam province

	Statistical Society	Sample	Percentage	
Ilam	900	130	%41	
Abadanan	150	30	%10	
Eyvan	200	30	%10	
Badreh	50	10	%3	
Chardavol	50	10	%3	
Darreh Shahr	100	20	%6	
Dehloran	100	20	%6	
Sirvan	50	10	%3	
Holeylan	50	10	%3	
Mehran	200	40	%12	
Malekshahi	50	10	%3	
Total	1900	320	%100	

Two library and field methods were used to collect the data; in this way, to collect the background and theoretical foundations of the research, the library method was used and four standard questionnaires were used to collect the information.

Data collection tool and technique

Demographic questionnaire: This general questionnaire includes seven questions about gender, age, marital status, income, work experience, occupation, and field of study, in which general and demographic information has been collected from the statistical sample.

Coronavirus anxiety questionnaire (CDAS): This questionnaire was prepared and validated by Alipour et al.[47] (2020) to measure anxiety caused by the spread of the coronavirus in Iran. The final version of this questionnaire has 18 questions and two subscales (factors), where questions 1 to 9 measure mental symptoms and questions 10 to 18 measure physical symptoms. This tool is on a four-point Likert scale, the highest score is 72, and the lowest score is 18, where a high score indicates a higher level of anxiety in people. The reliability of this tool has been obtained using Cronbach’s alpha method of 0.91, and its validity has been confirmed using exploratory and confirmatory factor analysis. Also, in this research, content validity was verified by ten expert professors, and its reliability coefficient was also obtained using Cronbach’s alpha of 0.86.

Baecke et al.’s physical activity questionnaire (1982): This questionnaire was used to collect information on physical activities and sports. This questionnaire has 25 questions, which includes three subscales called physical activities related to work (seven questions), physical and sports activities (14 questions), and physical activities related to leisure time (four questions). This tool is on a five-point Likert scale, the highest score is 125, and the lowest score is 25, where a high score indicates a higher level of physical activity. Baecke et al.[48] (1982) obtained the reliability of this tool with Cronbach’s alpha method of 0.73. Also, in this research, content validity was verified by ten expert professors, and its reliability coefficient was also obtained using Cronbach’s alpha of 0.87.

Ahvaz psychological hardness questionnaire: This questionnaire was prepared by Kiamarthi, Najarian, and Mehrabizade Honarmand (1998), and it has 27 questions that are graded on a four-point Likert scale, the highest score being 108, and the lowest score being 27. In this way, it is never given a grade of zero, rarely a grade of 1, sometimes a grade of 2, and most of the time a grade of 3. Also, questions 6, 7, 10, 13, 17, and 21 are graded in reverse. In this questionnaire, a higher score indicates a higher psychological hardness in people. Kiamarsi, Najarian, and Mehrabizade Honarmand[49] (1998) obtained the reliability of this questionnaire with Cronbach’s alpha of 0.76. Also, in this research, content validity was verified by ten expert professors, and its reliability coefficient was also obtained using Cronbach’s alpha of 0.84.

Professional identity questionnaire: This questionnaire was prepared and validated by Hao et al.[50] to measure professional identity among nursing students. This questionnaire consists of 17 questions and five subscales (professional personal image, job achievements, social comparison and self-reflection, professional independence, and social modeling). This tool is on a five-point Likert scale from strongly disagree (score 1) to strongly agree (score 5), where the highest score is 85 and the lowest score is 17, and a high score indicates more professional identity. Hao et al.[50] Cronbach’s alpha of this questionnaire obtained 0.83. Also, in this research, content validity was verified by ten expert professors, and its reliability coefficient was also obtained using Cronbach’s alpha of 0.91.

After collecting the data and to analyze them from descriptive statistics indicators such as percentage frequency, mean, standard deviation, minimum and maximum score and to check the hypotheses of the research, Pearson correlation coefficient test and structural equation model analysis with the help of SPSS statistical software and AMOS were used.

Ethical consideration

To comply with ethical considerations, the respondents had full authority to participate in this research, and they were informed that the results of the test will be provided to them if they wish. Finally, after obtaining informed consent from the subjects and announcing the confidentiality of the questionnaires, they started to complete the questionnaires.

Results

The descriptive results of the research showed that the highest frequency (163 people) is related to the age group of 31–40 years and the lowest amount (0 people) is related to the age group of less than 20 years. The number of participants with an associate’s degree or lower was 44, bachelor’s degree 184, master’s degree 37, doctorate 20, general practitioner 23, and finally 12 specialists. There were 115 men and 205 women, as well as 132 single and 188 married people. Descriptive indices and normality test are listed in Table 2.

Table 2 Descriptive indices and normality test of research variables

Research variables	Central tendency	Index of dispersion	Data normality test	
Mean	Standard Deviation	Skewness	Kurtosis	
Corona anxiety	3.23	2.25	0.55	-1.15	
Physical activities	2.65	1.72	-1.25	0.32	
Psychological hardness	3.17	1.22	1.15	1.18	
Professional identity	3.30	3.77	-0.50	1.33	

The values of Table 2 show that except for the variable of physical activities, almost the rest of the variables are at the average level (score 3). Also, the skewness and kurtosis coefficients of all research variables are in the acceptable range (+2 and -2); therefore, it is inferred that the data distribution is normal. To examine the conceptual model of the research, three different parts should be analyzed, including the measurement model (relationship between the questions and the underlying variable), the structural model (relationship between the underlying variables), and the general fit part of the model. The section of the measurement model mostly includes validity and reliability issues of the research conceptual model.

Based on Table 3 as well as the measurements obtained from the factor loadings of the measurement model [Figure 3] and their comparison with the desired reliability and validity value, it is possible to confirm the appropriateness of the reliability and validity of the research model.

Figure 3 Research measurement model

Table 3 Reliability and validity indices of variables

Variable	Factor Analysis	Cronbach’s alpha	Construct validity	Mean variance extracted	
Anxiety caused by corona	0.75	0.71	0.72	0.56	
Professional identity	0.81	0.91	0.91	0.66	
Physical activities	0.78	0.96	0.96	0.63	
Psychological hardness	0.74	0.84	0.88	0.61	

In the second part of the assumed model (structural model part), Pearson’s correlation coefficient and structural equation modeling have been used to test the proposed hypotheses. The results of the correlation test in Table 4 show that there is a significant relationship between the research variables at the 95% level; therefore, any change in one of the variables will be accompanied by a change in the other variables.

Table 4 Correlation coefficient related to research variables

Source	Frequency	Correlation value	P	
Physical activities and professional identity	320	0.498	0.001	
Professional identity and corona anxiety	320	-0.784	0.001	
Physical activities and corona anxiety	320	-0.631	0.001	
Psychological hardness and professional identity	320	0.584	0.001	
Psychological hardness and anxiety of corona	320	-0.725	0.001	

According to Table 4 and since the correlation method is not a suitable method for predicting the effect of independent variables on dependent variables and cannot properly explain the errors in the measurement and also ignores the effect of variables together, therefore, to investigate the effect of variables with their simultaneous presence together (in the form of a single model), the structural equation modeling method has been used in the following.

Figure 4 shows the path coefficients that indicate the intensity of the relationship and the influence of the independent variable on the dependent variable. The numbers on the paths show the coefficient of the path, the numbers inside the circles for the endogenous variables show the effect that the independent variables have on a dependent variable, and the numbers on the arrows of the hidden variables show the factor loadings. In the tested model, first, the significance of path coefficients and factor loadings was checked at the 0.95 level; according to Figure 4, it was observed that all factor loadings are significant at this level of confidence, which means that the correlation coefficient of manifest variables in the estimation of hidden variables related to themselves has the necessary ability, and as a result, it shows that the construct validity of the model is accepted. According to Figure 4, approximately 33% of the anxiety caused by corona is explained based on the variables of physical activities, psychological hardness, and professional identity, and the other 67% includes other dimensions. It can also be stated that sports activities and psychological hardness explain 62% of professional identity and 38% of it will be determined by other factors that are not considered in this research.

Figure 4 Structural model of the main research hypothesis

Based on the results of Table 5, In the hypothesis, the effect of physical activities on the level of anxiety caused by corona was indirectly investigated through the intermediary variable of professional identity with the Sobel test (1982), and the result was -3.76. In the Sobel test, the value of t is obtained through the following formula, and if this value exceeds 1.96, it can be confirmed that the effect of the mediator variable is significant at the 95% confidence level:

Table 5 Research hypotheses

Hypotheses	Independent Variable	Dependent Variable	Total Effect	Critical Ratio	Hypothesis Result	Description	
1	Physical activities and sports	Anxiety caused by corona	-0.19	-2.808	Hypothesis confirmation	Negative correlation	
2	Professional identity	Anxiety caused by corona	-0.29	-2.624	Hypothesis confirmation	Negative correlation	
3	Psychological hardness	Anxiety caused by corona	-0.53	-6.996	Hypothesis confirmation	Negative correlation	
4	Psychological hardness	Professional identity	-0.04	1.104	Hypothesis reject	Lack of correlation	
5	Physical activities and sports	Professional identity	0.79	1.355	Hypothesis reject	Lack of correlation	
6	The mediating effect of professional identity on the relationship between physical activities and anxiety caused by corona		0.55	-3.766	Hypothesis confirmation	Negative correlation	
7	The mediating effect of professional identity on the relationship between psychological hardness and anxiety caused by corona		0.02	-1.712	Hypothesis reject	Lack of correlation	

a: the value of the path coefficient between the independent variable and the mediating variable

b: the value of the path coefficient between the mediating variable and the dependent variable

Sa: the standard error of the path between the independent variable and the mediator variable

Sb: standard error of the path between the mediator and dependent variable.

Also, variance inclusion or VAF (VAF) is used to check the intensity of the mediating role of a variable. If the amount of variance inclusion is less than 20%, the role of mediation is rejected, if it is higher than 80%, the claim of mediation is accepted, and in a situation where the inclusion of variance is between these two values, the role of mediation is partial and moderate. The variance inclusion formula is as follows:

P12: path coefficient between independent variable and mediating variable

P23: path coefficient between the mediating variable and the dependent variable

P13: path coefficient between independent variable and dependent variable.

According to the variance inclusion formula (WAF), a value of 55% was obtained for the mediating role of professional identity in the relationship between physical activities and sports and the level of anxiety caused by corona. Therefore, the mediating role of professional identity in this relationship is partially and moderately accepted, and we conclude that there is a positive and meaningful relationship between physical activities and sports and the level of anxiety caused by corona through the mediating role of professional identity.

Also, in the hypothesis of the effect of psychological hardness on the level of anxiety caused by corona, it was investigated indirectly through the mediating variable of professional identity with the Sobel test (1982) and the result was -1.51. Considering that this rate is less than 1.96, the influence of the mediator variable is not significant and is not confirmed:

Also, for the mediating role of professional identity in the relationship between psychological hardness and the level of anxiety caused by corona, a value of 0.02% was obtained. Therefore, the mediating role of professional identity is rejected in this relationship, and we conclude that there is no relationship between psychological hardness and the level of anxiety caused by corona through the mediating role of professional identity:

The final part of the conceptual model of this research is related to the overall fit of the model. According to Table 6, the fit of the final model was confirmed.

Table 6 Final model fit

Indicator	IFI >0.9	RMR <0.8	CFI >0.9	RAMSE <0.8	
Model indicators	0.903	0.036	0.902	0.073	

Discussion

This research was conducted with the aim of modeling the structural equations of the anxiety level of corona based on psychological hardness and physical activities in the treatment staff of Ilam province with the mediator role of professional identity. The descriptive results of the research showed that the highest frequency (163 people) is related to the age group of 31–40 years and the lowest amount (0 people) is related to the age group of less than 20 years. The number of participants with an associate’s degree or lower was 44, bachelor’s degree 184, master’s degree 37, doctorate 20, general practitioner 23, and finally 12 specialists. Also, 44% of people had between 10 and 15 years of work experience in medical and health centers.

The inferential results of the research showed that physical activities and exercises have a significant inverse effect on the level of anxiety caused by corona which is consistent with the research findings of Hosseinpour and Godarzi (2022),Momtazbakhsh et al. (2021), Eskandarnejad, Alizadeh and Molayaei et al.. (2021), Psychou et al. (2020), Huang et al. (2020), and Li et al. (2020).[222930515253] And it does not agree with the results of the researches of Ströhle[54] (2009), Bartley et al.[55] (2013), and Pearsall et al.[56] (2014); Perhaps one of the reasons for the lack of effect of physical activities and sports on reducing the level of anxiety in previous researches was the level, intensity, and type of anxiety. But regarding the effect of physical activities and sports (aerobic, anaerobic, and all kinds of sports) on reducing the anxiety of the treatment staff, it seems that the anti-anxiety effects of sports activities can be explained based on various mechanisms, including spiritual and psychological. From the physiological point of view, sports activities can have anti-anxiety effects by providing a person with the possibility of achieving physical fitness, affecting the level of neurotransmitters, affecting the levels of stress hormones, and reducing muscle tension. From the spiritual and psychological aspect, sports activities can reduce anxiety by increasing the intensity of the activity and then providing a basis for increasing self-confidence and feeling of self-sufficiency; because stress and anxiety are caused by lack of self-confidence in people.[29] Also, regular physical activities reduce the function of the sympathetic nervous system and the axial activity of the hypothalamus-pituitary gland. This hormone plays an important role in the development of adaptive responses to physical and psychological stressors, and the disorder and disruption of this hormone for a long time in the emergence of depression symptoms and anxiety play a fundamental role.[57] Research has shown that sports activities can cause changes in the accumulation of monoamine receptors (norepinephrine, dopamine, or serotonin) or endogenous pain relievers (endorphin and enkephalin) and thus be very effective in positive mood changes. The beneficial psychological and social aspects of sports activities for stress and anxiety are also significant, which include the opportunity for social interactions, freedom from daily stressors, and the experience of feeling self-efficacy and self-efficacy and also, people who are physically active, compared to their inactive counterparts, show less symptoms of stress and depression.[58] Hosseinpour and Godarzi[29] (2022) stated that personal desire and interest in doing physical activities are an effective factor on the mental well-being and reducing the anxiety of the treatment staff. According to the results of the research, it is suggested that each person from the treatment staff should do sports and physical activities at home (with full compliance with health protocols) to reduce anxiety while paying attention to their wishes and interests. The results of the research of Skandarnejad, Alizadeh, and Molayaei[22] (2020) showed that there is a positive and significant correlation between the level of physical activities and anxiety and the ability to predict the level of anxiety of people based on their level of physical activities. So it can be concluded that physical activities and regular exercise through physiological, hormonal, and cognitive mechanisms may reduce the level of anxiety in people and increase their mental and physical health. Finally, the outbreak of COVID-19 has limited the conditions of doing physical activities and sports outside the house by creating restrictions in life with the aim of reducing the number of patients. Nevertheless, Rezaei[27] (2022) stated that regular and daily exercise at a time when many people in the world are living in isolation due to the spread of the corona disease plays an important role in helping to maintain physical and mental health as well as anxiety caused by the corona in different communities such as treatment staff.

Another result of this research was the significant and inverse effect of professional identity on the anxiety caused by corona, and no similar or inconsistent research was found in this field. In explaining this issue, it should be mentioned that probably the awareness and knowledge of the treatment staff about the nature of the COVID-19 disease have reduced their anxiety compared to other people in the society. Also, full compliance with health and treatment protocols is one of the other issues that have caused more self-confidence and less anxiety and stress for the treatment staff. Different strategies such as revising the job description, developing the participation of the treatment staff in decision-making, delegating authority, respecting and maintaining the value of the treatment staff, developing specialized training, and providing feedback on their professional performance can help to strengthen the self-confidence and expand the use of professional knowledge and skills of the treatment staff as a result of these solutions, and in acute and emergency situations such as the period of COVID-19, it reduces their stress and anxiety. Also, the findings of this research emphasize that professional identity reduces their anxiety because it adapts the attitudes and behaviors of the therapy staff to their professional roles. Also, not paying attention to the issue of professional identity in the treatment staff can cause weakness in communication skills and have an adverse effect on the level of social interaction of the treatment staff with clients and take opportunities to acquire mental, physical, and social skills from the treatment staff. Therefore, it is necessary to be aware of its dangers, and in this field, health and treatment centers should carry out extensive culture building. However, the research results of Ehsani Farid, Peikari, and Golshiri (2021) showed that the psychological imbalance and mental tensions of nurses in emergency situations are affected by the professional identity crisis.[59]

Also, the findings of the research showed that psychological hardness has a negative and significant effect on anxiety caused by corona, which is consistent with the findings of Kalhori (2021), Khosravian and Chahardoli (2021), Brooks et al. (2020), and Wang et al. (2020).[25606162] Kalhori (2021) stated that psychological hardness, coping strategies, and tolerance of chaos are effective factors related to the anxiety of the coronavirus, which can be considered in health and treatment centers. According to these results, it is suggested that during the outbreak of emerging and epidemic diseases, to reduce the anxiety of corona in the treatment staff, the concepts of psychological hardness, coping strategies, and tolerance of disturbance should be taken into the attention of the managers and officials of the Ministry of Health. It seems that psychological hardness reduces the stress and anxiety related to COVID-19 by increasing the power of endurance and tolerance against hardships and believing in coping with illness and pain. Among other reasons and explanations of this hypothesis, we can mention the variable nature of stubbornness. Stubbornness as a psychological construct guarantees positive coping with problems and bearing the pressures of life. People with psychological hardness in difficult situations adapt themselves to those conditions more easily and can accept its challenges and, as a result, choose a more favorable coping strategy. However, due to the underlying nature of psychological hardness in difficult spiritual and emotional situations, people who have a higher level of psychological hardness are less damaged by the pressures of the external environment. Such characteristics of psychological hardness make people define conditions like the COVID-19 disease in a more balanced way, thus preventing its damage. In fact, it can be said that people with favorable levels of psychological hardness, due to the existence of fighting qualities and self-expression and endurance in the face of stressful environmental events, are less likely to suffer physical and mental injuries; therefore, the importance and necessity of strengthening psychological hardness in different societies are revealed. Researches indicate the role of psychological hardness in reducing anxiety of corona in students and improving mental well-being in nurses.

Other research findings showed that physical activities and sports through professional identity have an inverse and significant effect on anxiety caused by corona. According to the variance inclusion formula (WAF), a value of 55% was obtained for the role of professional identity in the relationship between sports activities and anxiety caused by corona, and the mediating role of professional identity was accepted as moderate. In explaining this finding, it can be stated that institutionalizing the category of professional identity is one of the most important issues that can affect the performance of the treatment staff. Therefore, it seems necessary to pay attention to factors such as collaborative activities, holding and promoting in-service training courses, and logical matching between practical and theoretical courses for the development of the professional identity of the treatment staff. Another thing that should be considered to achieve a professional identity in the treatment staff is team and communication activities. Because teamwork is one of the essentials of the therapy staff’s profession due to the creation of professional relationships, increasing motivation, reducing job abandonment, and reducing stress and anxiety.

Limitation and recommendation

Therefore, to strengthen and promote the professional identity among the medical staff of Ilam province, the following are suggested to the managers and decision-makers of health and treatment centers:

Forming training workshops to promote professional identity to increase the self-confidence and self-belief of the treatment staff is an incumbent and necessary thing that managers should pay attention to.

Creating more commitment of the treatment staff by involving and participating them in decision-making can improve their professional identity and thus reduce the anxiety of the treatment staff.

Holding meetings and group activities can cause more interaction between the treatment staff, especially considering the characteristics of the working environment of health and treatment centers, creating an interactive atmosphere combined with intimacy and friendship can cause the growth and development of professional identity.

Consistency between theoretical and clinical training courses, presentation of a clear and acceptable image of the profession of the treatment staff, compliance with the moral values of the work environment, independence in clinical activities, etc., are effective factors in creating a positive professional identity.

The findings of various studies show that adults aged 18 to 64 should have at least 150 minutes of moderate-intensity sports activities per week (or 75 minutes of intense sports activities) in two or more training sessions. Therefore, these conditions should be provided for the treatment staff (xample.g. morning exercise or facilitating access to sports facilities, etc.).

It is suggested that future researchers do this in other ways, such as qualitative methods, or in other communities, such as teachers and club coaches.

Conclusion

Finally, the findings of this research led to the expansion of information in the field of the necessity of doing sports activities, the professional identity of the treatment staff and anxiety caused by corona, and showed that sports activities and professional identity have an effect on the anxiety caused by corona among medical staff in Ilam province, and with the variable of professional identity, it is possible to strengthen the relationship between sports activities and corona anxiety.

Financial support and sponsorship

The study was financially supported by the Ilam University, Iran.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

This article is extracted from the Master’s thesis of the Sports Science Department of Ilam University. We are grateful to all the medical staff of the health and treatment centers of Ilam province who helped us in this research.

Code of ethics: IR.ILAM.REC.1400.004
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