Journal of Occupational

Introduction
The COVID-19 outbreak has had a significant impact on many aspects of individual and social life. The consequences of the COVID-19 crisis have led to the disruption of normal communication among health care providers and patients. Effective communication during a crisis plays an essential role in reducing uncertainties, thereby reducing the psychological impacts experienced by people [1]. As many researchers had predicted, the COVID-19 pandemic would likely continue to spread widely across the globe throughout 2020-2021 [2, 3]. Social distancing and visitor restrictions in health care facilities have been widely implemented to diminish the devastating impact of the disease. Although very effective in controlling the disease, these policies and practices have complicated communication among healthcare workers and patients [4].
Communication as a key factor for improving patient health is vital for the refugees  [5]. Also, the life-saving care for non-communicable and chronic infectious diseases, including diabetes and HIV/AIDS, is another critical issue for refugees [6]. Communication barriers, specifically communication apprehension (CA), are factors that cause stress and put a high demand on both refugees and health care professionals. CA is an individual fear and anxiety associated with either real or anticipated communication with another person or persons [7, 8].
A study carried out in the European health care system indicates insufficient language knowledge as the main cause of communication barriers [11]. Refugees experience anxiety that is intensified as they are, in most cases, unable to return to the country of their origin, and this fact contributes to their mental distress [12]. Another factor that may act as a barrier to the refugees' communication with the healthcare team is the fear that care will be denied [13].  Based on the world health organization reports, refugee women are at higher risk of mental and physical health problems due to such factors as lack of social support, discrimination, and poverty  [14, 15]. It has been reported that over half of the refugee population are women [16], most often with young children. Yet, they often remain underrepresented and marginalized in both care settings and at home, receiving insufficient consideration and support due to socio-cultural and language barriers [17]. Without the aid and support of their immediate families as wives and/or mothers, these women have to bear more burden in the process of immigration in order to support their family members and adjust to a new way of living [18].
Long before the outbreak of COVID-19, studies of communication problems had gained attention, and Richmond et al., among others, recommended that "future research should investigate the impact of physicians' engagement in positive communication behaviors on the patients' apprehension and medical outcomes" [19]. Another obstacle that has not received considerable attention and prevents adequate medical care is Fear of Physician (FoP) [20]. Richmond et al. found out that CA and FoP were positively related [19].
FoP is a common phenomenon and affects all people, no matter old or young. Usually, people who suffer from this difficulty ask fewer questions regarding their health care, thus losing their autonomy in their health care issues. Ahmed and Bates point out that this fear is sometimes so severe that patients avoid licensed physicians and refer to "informed sources of healthcare" [21]. Differences in communication skills, education, ethnicity, gender, language, and socioeconomic status, are the major causes of this fear [22].  FoP is also associated with a variety of negative relationships and clinical outcomes.
Refugees, especially minority women, have been studied regarding their level of CA; however, few studies have been conducted in the clinical setting and face-to-face contact with physicians and health care workers. The current study adds to this body of literature by exploring CA among the refugee women living in the South East of Iran, who are also of a low socioeconomic status (SES) due to political, social, and economic reasons. To the best of our knowledge, no earlier study has been conducted in the same scope in Iran. Thus, this study aims to investigate the experiences of Communication Apprehension (CA) and Fear of Physician (FoP) in the Afghan refugee women referred to the Iranian health care clinics during the COVID-19 pandemic in the year 2020 in Rafsanjan, Iran.

Materials and Methods
This was a descriptive cross-sectional study. The research population consisted of 237 Afghan women referred to two Family Health Centers (FHC) in the city of Rafsanjan, Iran, which are run under the supervision of the United Nations High Commission for Refugees (UNHCR) and Rafsanjan University of Medical Sciences. We calculated the study sample size by

 
formula with the effect size of 1, confidence interval of 95%, and standard deviation of 6.46 based on an earlier study [23]. We determined a sample size of 160. Considering the possibility of sample loss, 240 participants were estimated.  They were selected by the convenience method in March–July 2020.  Being alert and aware of the time and place, being able to speak Persian, having no psychiatric diseases, taking no neuropsychiatric drugs, being able to participate in research and collaboration, and signing the informed consent form were the inclusion criteria for this study. The unwillingness to participate in the research and incomplete questionnaires were the exclusion criteria. Finally, 237 persons completed the questionnaires.
Data collection tools included a demographic (including age, husband's age, religion, birthplace, number of family members, number of children, educational level, marital status, history of illness, and accommodation status), Personal Report of Communication Apprehension (PRCA-24), and FoP questionnaires. PRCA-24 is a scale designed to measure one's fear associated with either real or anticipated communication in four different dimensions (public speaking, group discussion, meeting, and interpersonal), devised by McCroskey in 1972 and underwent several revisions in 1978 and 1982. The interpersonal dimension is the level of fear or anxiety associated with either real or anticipated communication with another individual in face-to-face interaction. Meeting and group discussion dimensions are related to the level of fear or anxiety emerging during the meetings or small group gatherings. The public speaking dimension is the type of CA that most people deal with when the situation arises. The scores range of this questionnaire is between 24 –120 overall and between 6-30 for each subdomain. Scores between 83 -120 indicate a high level of communication apprehension, scores between 55-83 show a moderate level of communication apprehension, and scores between 24-55 indicate a low level of communication apprehension. Beatty et al. point out that these four contexts are highly related to one another [24]. PRCA-24 has high predictive validity and reliability (Cronbach's alpha, >0.90). In Iran, the validity and reliability of this questionnaire were confirmed by Hashemi et al. [23]. The scale uses 24 five-point Likert items, ranging from 1 ("Strongly disagree") to 5 ("Strongly agree"), and it may be overall scored by adding up the rating of the 24 items, or it can be computed separately for each dimension. The participants also filled out a 5-item state anxiety measure developed by Spielberger (1966). Many people are fearful and/or anxious about communicating with their physicians. It is believed that this fear/anxiety is, in some part, a function of the way the physician communicates with the
patient. This FoP instrument was developed to measure this feeling (score range between 5-20). Alpha Cronbach reliability estimates for these instruments should be expected to be near 0.90 (19). Data were collected by Afghan health care workers in the two FHC using face-to-face interview methods; if the participants were literate, they filled out the questionnaires by themselves. The protocol of the study was approved by the ethics committee of Rafsanjan University of Medical Sciences (IR.RUMS.REC.1398. 152) in terms of bioethics considerations. Therefore, permission was obtained from the ethics committee of Rafsanjan University of Medical Sciences to have the COVID 19 in the title and the manuscript. All the data by chance were gathered during the COVID outbreak and might have affected the results. The study objectives were explained to the participants, with their names and information kept confidential.
The data were analyzed using descriptive and analytical statistics (Independent t-test, as well as ANOVA, Chi-square, and Fisher exact tests) using SPSS software version 20.0 (SPSS Inc., Chicago, IL). The significance level was less than 0.05.

Results
A total of 237 women participated in this study. The mean age of the participants was 28.81 ± 7.21 years, and their ages ranged from 16 to 60 years old. The mean age of the participants' husbands was 31.31 ± 10.02 years, and their ages ranged from 20 to 73 years old. The majority of participants (97.9%) were married. The birthplace of the majority (63.3%) was Iran. Further, the majority of the women were Sunni Muslims (142 persons: 59.9%). Frequencies of other demographic characteristics are presented in Table 1.
Based on the results, the overall mean score of PRCA was 67/07 ± 15.68 /15/59 ± 5.31, 15/96 ± 4.78, 16/91 ± 4.79, and 18/60 ± 5.43 for subdomains of group discussion, meeting, interpersonal, and public speaking, respectively. The overall mean score of FoP was 14.29±2.83. Moderate to severe anxiety (CA) was revealed in 199 participants (84%), while 235 participants (99.2%) had moderate to severe FoB (Table 2). Regarding FoP, 57.8% of the participants (137 persons) reported an extreme degree of FoP while visiting the clinics.