Challenges and Barriers to Effective COVID-19 Screening at Iran’s Air Border Crossings: A Qualitative Study and Proposed Solutions

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Effective screening at these points is vital for national health security and meeting global health obligations under the revised International Health Regulations (IHR 2005). This qualitative study aimed to identify and analyze the challenges, barriers, and proposed solutions in COVID-19 screening and management at Iran’s air border crossings and situates these findings within the context of global health governance and pandemic response frameworks. Methods Using purposive sampling, twelve key stakeholders involved in border health management were interviewed between Mar and Nov 2024. Data were collected through semi-structured interviews and supplemented by a field visit to Imam Khomeini International Airport’s border health bas and a review of relevant international regulations and recent scholarly literature. Content analysis combined with Fishbone root cause analysis was employed to explore underlying factors. Results Findings revealed multifaceted challenges including inconsistent implementation of screening protocols, shortage of trained personnel, inadequate technological infrastructure, poor interagency coordination, and legal ambiguities related to data privacy and quarantine enforcement. Behavioral factors such as passenger resistance and limited airline cooperation further undermined screening effectiveness. Additionally, the assessment identified significant gaps in meeting global standards and International Health Regulations core capacities (points of entry, public health emergency preparedness and surveillance) at air border points. Proposed solutions emphasized integrated digital platforms for real-time data sharing, enhanced staff training, improved quarantine facilities, legal reforms, and targeted multilingual communication campaigns. Conclusion This study indicates that strengthening air border screening during pandemics requires a multisectoral approach aligned with international health regulations. Identified human, technical, organizational, legal, and environmental challenges may hinder full compliance with these regulations. Addressing these barriers through practical solutions could improve preparedness and response to health emergencies at both national and international levels. Border Health Infectious Diseases Pandemic Preparedness Management Airport Figures Figure 1 1. Introduction Emerging and re-emerging respiratory viral diseases with high transmissibility, such as COVID-19, seasonal and pandemic influenza, SARS, and MERS, have posed major challenges to health systems worldwide, particularly at international border points ( 1 – 3 ). The rapid global spread of COVID-19 since late 2019 has highlighted the critical role of international borders, especially air border crossings, as frontline defense points in preventing cross-border transmission of infectious diseases ( 4 ). Effective screening and management at these points are essential not only for national public health security but also for global health security, in line with the objectives set by the World Health Organization’s International Regulations (IHR 2005) ( 5 , 6 ). The IHR framework mandates countries to develop and maintain core capacities at points of entry, including airports, to detect, assess, report, and respond to public health emergencies of international concern (PHEIC). Recent revisions and updates to the IHR emphasize enhanced surveillance, real-time data sharing, and multisectoral coordination to strengthen border health management during pandemics ( 7 , 8 ). Given the transnational nature of respiratory pandemics, failures or gaps in border screening can have significant repercussions beyond national boundaries, underscoring the importance of aligning local practices with global regulations and standards. Air border points play a pivotal role in preventing the entry of suspected or confirmed cases and thus are central to infection control policies. Screening methods at these sites typically include self-reporting, vital sign monitoring (e.g., fever), rapid molecular or antigen testing, as well as quarantine and contact tracing procedures ( 9 ). The effectiveness of these measures directly influences viral spread within communities by preventing new case introductions ( 10 ). Despite their importance, screening processes at airports face multiple challenges that undermine their effectiveness. Key obstacles include shortages of trained personnel, inefficient technologies and information systems, poor organizational coordination, inadequate infrastructure, and financial constraints ( 11 , 12 ). Additionally, travelers’ behavioral and cultural factors, such as resistance to health protocols, misinformation, and lack of awareness, significantly affect control efforts ( 13 , 14 ). Global experiences during the COVID-19 pandemic demonstrate that leveraging advanced technologies such as digital health platforms, artificial intelligence, and integrated data systems can substantially improve the effectiveness of border health measures ( 15 – 17 ). Countries like South Korea and Singapore have showcased successful models of data-driven, coordinated border screening and contact tracing, contributing to rapid containment of viral spread ( 18 , 19 ). Furthermore, appropriate environmental infrastructure and optimal ventilation in airport spaces are recognized as important factors in reducing respiratory disease transmission ( 20 ). Moreover, challenges such as legal and ethical issues related to data privacy, passenger compliance, and interagency coordination have emerged as common barriers worldwide, necessitating comprehensive policy responses within the global health governance framework ( 17 , 21 ). Despite the global importance of these issues, there remains limited in-depth qualitative research focusing on operational challenges and contextual barriers faced by countries like Iran in implementing effective COVID-19 screening at air borders ( 22 , 23 ). Iran was among the early countries to experience imported COVID-19 cases. Iran’s unique social, cultural, economic, and infrastructural contexts, combined with its significant passenger traffic and geopolitical position, present both challenges and opportunities for improving border health management in ways that can inform global policy discourse ( 24 , 25 ). Moreover, insufficient attention to behavioral and cultural dimensions, weak inter-organizational coordination, and legal complexities regarding data privacy have been identified as key barriers needing resolution in operational settings ( 26 ). Therefore, this study aims to identify and analyze the challenges, barriers, and proposed solutions related to COVID-19 screening and management at Iran’s air border crossings, while situating these findings within the broader context of international health regulations and global pandemic response strategies. By integrating qualitative insights with a review of global scientific literature, this research seeks to contribute to the understanding of how national-level experiences can inform and be informed by global-level health security frameworks, supporting evidence-based policy-making in pandemic preparedness and responses. 2. Methods 2.1 Study Design and Approach: This qualitative study employed a content analysis approach to examine COVID-19 screening and management processes at Iran’s air border crossings, aiming to identify challenges and improvement opportunities. The qualitative method was chosen for its ability to deeply explore experiences and perspectives of key stakeholders. In addition to primary qualitative data collection, a comprehensive review of international health regulations, including the International Health Regulations (IHR 2005) and recent updates, as well as global pandemic response literature, was conducted to frame the analysis within global health governance and policy contexts. This dual approach ensures that the study’s findings not only reflect national realities but also contribute to international policy discourse [The details of the methodology, along with a review of global guidelines and scientific literature, are presented in a Ph.D. thesis by HP, titled “Development and Local Adaptation of a Screening Method and Management of Acute Respiratory Viral Infections in Aerial Entry Points”, at the School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Iran]. This study was conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure rigor and transparency. 2.2 Study Population and Sampling: The target population included key experts involved in border health management, airport healthcare, infectious disease control, and crisis management at Iran’s air borders. Participants were recruited through official channels and professional networks, ensuring representation of diverse stakeholder roles, and with a response rate of 80%. Participants comprised border health managers, infectious disease specialists, airport healthcare providers, IT experts related to health systems, and airline representatives. Purposive sampling was used to select individuals with practical experience and expertise in COVID-19 screening and management at airports. Eligibility criteria required at least five years of relevant experience, involvement in border health programs, and willingness to participate. Sampling continued until data saturation was reached, achieved after twelve interviews. 2.3 Data Collection: Semi-structured interviews, guided by open-ended questions, explored various aspects including pre-travel, airport, and post-entry screening processes; screening tools and technologies; isolation and quarantine procedures; contact tracing and case management; training and awareness for passengers and staff; existing challenges; and suggestions for improvement. The open-ended format allowed themes to emerge naturally from participants’ responses. The interview guide (Table 1 ) included main questions on challenges, barriers, and solutions, accompanied by probing questions to deepen the discussion. The interview guide was developed through a systematic process to ensure clarity, relevance, and comprehensiveness. Initially, a draft guide was created based on the study objectives, relevant literature on COVID-19 border health management, and input from subject matter experts in infectious diseases and public health. To enhance validity and practicality, the draft interview guide was pilot-tested with two healthcare professionals experienced in border screening but not involved in the main study. Feedback from these pilot interviews focused on question clarity, flow, and comprehensiveness. Based on pilot results, ambiguous or leading questions were revised, and additional probes were incorporated to elicit more in-depth responses. The guide was iteratively refined to balance open-ended questions that encourage rich narratives with focused prompts aligned to the study’s thematic areas. Table 1 Interview Questionnaire: Open-Ended Questions Main Questions Probing Questions Challenges 1. Can you describe the main challenges you have encountered in the COVID-19 screening process at the air border? - Could you give specific examples of when these challenges occurred? - How do these challenges affect your daily work or overall process effectiveness? - Are these challenges related to resources, procedures, or people? 2. What difficulties have you noticed in managing isolation and quarantine for travelers? - How adequate are the current facilities and resources for quarantine? - Have you faced any issues with compliance or enforcement? - What factors contribute most to these difficulties? 3. What obstacles exist regarding contact tracing of passengers who may have been exposed to COVID-19? - Are there any technical or organizational barriers to accessing or sharing information? - How timely is the contact tracing process in practice? - What are the main causes of delay or failure in tracing contacts? 4. How effective do you find the communication and awareness efforts directed at passengers? - What communication methods are used? - Are passengers generally cooperative and well-informed? - What challenges do you face in reaching diverse passenger groups? 5. What challenges do staff face in carrying out their responsibilities related to COVID-19 screening and management? - How sufficient is the training and support for staff? - Are there issues related to motivation, workload, or coordination? - How do staff perceive their roles and responsibilities? 6. What legal or organizational challenges affect the COVID-19 management process at the border? - Are there clear policies and regulations in place? - How well do different organizations coordinate and communicate? - Have you experienced any conflicts or gaps in authority? - How does your organization incorporate or comply with international regulations such as the International Health Regulations (IHR 2005) during screening and management? Suggested Solutions 7. In your opinion, what changes or improvements could help overcome the challenges you mentioned? - Are there specific technologies or systems that could be introduced or improved? - what role do you think alignment with global health guidelines and frameworks plays in improving border health management? 8. How could the infrastructure for isolation and quarantine be improved? - What resources or facilities are currently lacking? 9. What steps could be taken to improve the contact tracing process? - How can data sharing and interagency cooperation be enhanced? 10. What strategies would you recommend to enhance passenger awareness and communication? - 11. What legal or policy reforms do you think are necessary to support better COVID-19 management at the border? - Are there gaps or ambiguities in current regulations? Interviews were conducted face-to-face in a private office or by phone, based on participant preference, and with informed consent, and lasted 60–80 minutes. All interviews were audio-recorded with consent and transcribed verbatim. To ensure accuracy, transcripts were cross-checked by the research team. Field notes supplemented audio recordings, capturing non-verbal cues and environmental context. In addition, a field visit to the border health base at Imam Khomeini International Airport was conducted to observe physical settings, equipment, staff deployment, and operational procedures such as sample collection and documentation, offering practical insights into current conditions. 2.4 Interviewers characteristics: Interviews were conducted by [HP /author], who is experienced qualitative researcher with backgrounds in infectious disease control and public health. The interviewer had no prior relationship with participants, minimizing potential bias. Reflexivity was maintained by documenting assumptions and discussing potential biases within the research team. Field notes were kept to capture contextual observations and interviewer impressions. 2.5 Data Analysis: Based on the research questions, a directed content analysis approach was employed to analyze the interview transcripts. Initially, the data were systematically coded according to predefined categories aligned with the study objectives, and subsequently, categories and sub- categories were identified and organized to reflect the underlying patterns and groupings. This process was facilitated using MAXQDA software (version 24). Two researchers independently coded the transcripts. Discrepancies were resolved through discussion until consensus was reached. To deepen the understanding of the identified challenges, a root cause analysis was conducted using the Fishbone (Ishikawa) framework, categorizing causes into five main domains: human, technical, organizational, legal, and environmental factors. An audit trail documented coding decisions and theme development. This combined approach enabled a comprehensive exploration of the issues and supported the development of targeted recommendations( 27 ). 2.6 Trustworthiness Measures: To enhance credibility and reliability, several strategies were employed: member checking (participants reviewed summaries and codes for accuracy), independent coding by two researchers with consensus discussions, thorough documentation of data collection and analysis procedures to ensure reproducibility, and repeated transcript reviews to ensure comprehensive and precise coding. Thick descriptions of context and participant quotes were included to enhance transferability of findings. 2.7 Ethical Considerations: All participants voluntarily consented after being informed about study objectives and data usage. Confidentiality and anonymity were strictly maintained. Audio files and transcripts were securely stored on encrypted devices accessible only to the research team and will be retained for five years in accordance with institutional policy. This study was conducted in accordance with ethical standards, and ethical approval was obtained from the relevant committee (Code: 1402.135REC.PHNS.SBMU.IR). 2.8 Methodological Limitations: Although carefully designed, limitations include the purposive sampling and limited number of interviews, which may not capture all perspectives. Response bias is also possible. Nevertheless, validity checks employed mitigate these limitations substantially. To reduce interviewer bias, interviewers followed a standardized guide and reflected on their positionality throughout the research process. 3. Results 3.1 Field visit findings: A field visit to the border health base at Imam Khomeini Airport revealed multiple operational and structural challenges in COVID-19 screening and management at Iran’s air border crossings. The most notable issue was the absence of comprehensive guidelines and cohesive educational resources, resulting in fragmented, unsystematic, and somewhat discretionary implementation of procedures. Although basic medical equipment such as examination beds, vaccine refrigerators, and handheld thermometers were available, they were insufficient for comprehensive screening. Advanced technologies for data recording, tracking, and analysis were largely underutilized. Self-declaration forms distributed by flight crews were often incomplete and unreliable due to limited airline cooperation. Vaccination and test result verifications were conducted manually, sometimes using staff personal internet connections, causing delays and allowing fraudulent documentation. Sampling processes, including rapid tests and PCR, experienced significant result turnaround delays. A critical shortage of specialized personnel, including doctors, nurses, and laboratory staff, placed extensive responsibilities on health monitors, adversely affecting quality. Lack of a designated authority to enforce health protocols led to poor mask use, inadequate social distancing, and insufficient ventilation in terminals, increasing transmission risk, particularly amid passenger congestion at entrances. Quarantine procedures lacked defined teams and oversight frameworks; some travelers left quarantine prematurely due to incomplete follow-up or intermediaries, revealing weaknesses in enforcement. Overall, the field visit emphasized the need for structural reforms, enhanced IT infrastructure, strengthened specialist workforce, expanded training and awareness, and comprehensive, practical guidelines to improve screening and disease management at air borders. 3.2 Interview Findings: Twelve stakeholders participated in semi-structured interviews, were interviewed between Mar and Nov 2024. The Table 2 presents the demographic and professional profiles of study participants. Participants were interviewed, including 9 males and 3 females, with ages ranging from 38 to 62 years. Their professional experience in relevant fields ranged from 7 to 20 years (mean = 15 years). Pseudonyms (e.g., P1, P2) are used to maintain confidentiality in reporting quotes. Table 2 Demographic and professional profiles of study participants Participant No. Gender Expertise and Educational Degree Position/Role Years of Experience 1 Male Ph.D. of Epidemiology Head of Border Health Department 15 2 Male Ph.D. of Epidemiology Coordinator, Health Ministry & Border Care 10 3 Male MD, MPH Head, Airport Border, Ministry of Health 20 4 Female MSc in Public Health Airport Border Healthcare Officer 13 5 Female BSc in Public Health Border Health Screening Staff 8 6 Male Ph.D. of Epidemiology Infectious Disease Epidemiologist 15 7 Male Ph.D. of Epidemiology Vital Statistics Specialist 20 8 Male Ph.D. of IT IT Specialist 14 9 Male Ph.D. of Health Education Health Education Specialist 18 10 Male MD, MPH Head, Infectious Diseases Group 20 11 Male MSc in HSE Airport Safety Officer 7 12 Female MD Infectious Disease Specialist Physician 19 The analysis of interviews revealed multiple, interrelated challenges affecting the effectiveness of COVID-19 screening and management at Iran’s air border crossings. One of the main challenges concerns the screening and passenger assessment processes. While protocols such as syndromic evaluations, temperature checks, and self-report forms are in place, their implementation is often inconsistent and fragmented. This inconsistency stems from unclear or outdated guidelines specific to air border contexts and is compounded by poor coordination between airlines, airport staff, and health authorities. The reliance on paper-based self-report forms, which are frequently incomplete or inaccurately filled, reflects both limited passenger cooperation and weak airline engagement. Moreover, technological limitations, including insufficient availability of advanced screening devices and lack of integrated digital data systems, hamper efficient case identification and monitoring. Behavioral resistance from passengers, driven by fears of quarantine or stigma, further reduces the accuracy and reliability of screening efforts. Additionally, the shortage of well-trained and motivated personnel exacerbates these issues, as staff often lack continuous education and adequate support to maintain high-quality assessments. Isolation and quarantine management present another significant challenge. The existing physical infrastructure is inadequate, with a shortage of properly ventilated and equipped isolation spaces within airports. The absence of multidisciplinary teams responsible for clinical care and quarantine monitoring results in inconsistent enforcement and follow-up. Legal ambiguities and weak enforcement mechanisms limit authorities’ ability to mandate quarantine, causing some travelers to prematurely leave isolation areas. The overcrowding of terminal spaces combined with poor ventilation increases the risk of in-terminal transmission. Furthermore, foreign travelers bear the financial burden of hotel quarantine without sufficient oversight, which sometimes undermines compliance. These factors collectively weaken the effectiveness of isolation measures crucial for controlling disease spread. Contact tracing efforts are hindered by restricted access to passenger data, largely due to privacy laws and fragmented interagency cooperation. Without standardized communication protocols and integrated data-sharing platforms, contact tracing remains manual, delayed, and incomplete. The lack of cooperation from airlines and other stakeholders further complicates timely identification and follow-up of potential contacts. Passenger awareness and sensitization efforts primarily rely on traditional communication methods such as banners and pamphlets. Given passengers’ short transit times and the linguistic and cultural diversity of travelers, these methods have limited effectiveness. Fragmented messaging, resulting from weak collaboration among health authorities, airport management, and airlines, further diminishes the impact of awareness campaigns. Human resource constraints represent a cross-cutting barrier influencing many operational aspects. There is a notable shortage of specialized and adequately trained personnel to conduct screening, manage quarantine, and perform follow-up activities. Staff motivation is often low due to repetitive tasks, insufficient psychological support, and lack of incentives, all contributing to reduced quality and consistency of interventions. Finally, legal and organizational frameworks are characterized by ambiguities and gaps. The absence of clear policies regarding data privacy, quarantine enforcement, and defined interagency roles results in fragmented responsibilities and poor coordination. Without strong legal backing and multisectoral governance mechanisms, implementation of health protocols becomes inconsistent and ineffective. Several participants highlighted the challenges in fully implementing the International Health Regulations (IHR 2005) core capacities at air border crossings. They emphasized the need for clearer legal mandates, standardized protocols aligned with WHO recommendations, and enhanced multisectoral and interagency coordination to meet global health security requirements. These gaps affect not only national pandemic response effectiveness but also Iran’s compliance with international obligations during Public Health Emergencies of International Concern (PHEIC). To address these interconnected challenges and underlying barriers, stakeholders proposed a range of solutions. These include the development of integrated, web-based digital platforms that enable real-time data sharing and monitoring across agencies. Advanced technologies such as artificial intelligence for symptom detection and QR code-based self-reporting were recommended to enhance screening accuracy and passenger compliance. Strengthening staff training programs, including continuous education and psychological support, was emphasized to improve workforce capacity and motivation. Enhancing collaboration with airlines ensures better engagement and data completeness. The establishment of dedicated, well-ventilated isolation and quarantine facilities staffed by multidisciplinary teams would improve management and enforcement. Legal reforms to clarify enforcement powers, data privacy, and interagency roles, alongside formal agreements to foster cooperation, were identified as essential. Additionally, launching targeted, multilingual pre-travel awareness campaigns and employing modern digital communication tools would improve passenger sensitization and adherence to health protocols. Table 3 shows the summary of challenges, barriers, and proposed solutions. Table 3 Summary of Challenges, Barriers, and Proposed Solutions Category Subcategory Codes (Key Concepts) Sample quote Challenges & Barriers Screening and Passenger Assessment Incomplete self-report forms, inconsistent protocol application, limited technology use, poor coordination, passenger behavioral resistance, inadequate training Participants reported inconsistent application of protocols and incomplete self-report forms as major obstacles. “Many passengers do not fill the forms properly, and we have limited technology to verify their answers,” explained P3 (Head, Airport Border, Ministry of Health). “Sometimes the guidelines change frequently, and we don’t get timely updates, so each shift applies different rules.” (Participant 4, Airport Healthcare Officer). “Sometimes the thermal scanners were removed, and manual temperature checks were used, but these are not very reliable, especially for acute respiratory diseases. Environmental factors and passenger movement affect accuracy.” (Participant 1, Head of Border Health Department). “Flight crews distributed self-declaration forms, but many were incomplete or passengers wrote unrelated notes. Cooperation from airlines was insufficient.” (Participant 5, Border Health Screening Staff) “Passengers are often in a hurry, worried about their luggage or family, and reluctant to cooperate fully with screening.” (Participant 1, Head of Border Health Department) “We had no integrated digital system; verifications of vaccinations or test results were done manually, sometimes even using staff personal internet connections, leading to delays and allowing fraudulent documents.” (Participant 5, Border Health Screening Staff). Isolation and Quarantine Management Insufficient isolation facilities, lack of specialized teams, weak legal enforcement, overcrowded and poorly ventilated spaces, financial burden on travelers “We lack enough well-ventilated isolation rooms, and the enforcement of quarantine is weak due to legal gaps,” noted P6 (Infectious Disease Epidemiologist). “There was no proper isolation space at the airport; some travelers left quarantine early due to poor follow-up and lack of enforcement.” (Participant 5, Border Health Screening Staff). “We can educate families about quarantine, but strict enforcement is lacking because of unclear laws. A traveler can easily leave quarantine without consequences.” (Participant 10, Head of Border Health Department). “Foreign travelers bear the cost of hotel quarantine, which affects their willingness to comply strictly.” (Participant 5, Border Health Screening Staff) Contact Tracing and Follow-Up Restricted data access due to privacy laws, fragmented interagency cooperation, manual and delayed data processing, lack of standardized communication channels “Access to passenger data is restricted by privacy laws, and cooperation between agencies is limited, which delays tracing,” stated P8 (IT Specialist). “We sometimes received advance emails listing passengers exposed to cases, but immediate follow-up at the airport was difficult due to legal and logistical barriers.” (Participant 1, Head of Border Health Department). “Without integrated systems and formal agreements, contact tracing remains manual and slow.” (Participant 8, IT Specialist). Passenger Awareness and Communication Limited impact of traditional methods, short transit time, linguistic and cultural diversity, fragmented messaging, weak intersectoral collaboration “Traditional methods like banners are not very effective given the short transit time and language barriers,” remarked P9 (Health Education Specialist). “Passengers are often too busy or distracted to engage with health messages. We need to use modern technologies like mobile notifications with links to health info.” (Participant 1, Head of Border Health Department). “Different authorities send different messages; there is no unified communication strategy.” (Participant 9, Health Education Specialist). Human Resources and Training Staff shortages, insufficient continuous education, low motivation, burnout, lack of psychological support “Staff are overworked and lack ongoing training, which affects motivation and performance,” commented P5 (Border Health Screening Staff). “There is a shortage of doctors and nurses; health monitors bear excessive responsibilities, leading to burnout and inconsistent quality.” (Participant 5, Border Health Screening Staff). “Staff often work just to fulfill minimum duties. Lack of incentives and recognition reduces enthusiasm.” (Participant 3, Head, Airport Border, Ministry of Health). Legal and Organizational Frameworks Ambiguous data privacy laws, weak quarantine enforcement policies, unclear interagency roles, poor coordination among stakeholders, incomplete implementation of International Health Regulations (IHR 2005) “There is confusion about roles and responsibilities, and no strong legal backing for quarantine enforcement,” emphasized P2 (Coordinator, Health Ministry & Border Care). “Legal frameworks are vague; quarantine enforcement is weak, and no single agency has clear authority.” (Participant 1, Head of Border Health Department). “A unified management structure and legal reforms are essential to empower enforcement and data sharing.” (Participant 12, Infectious Disease Specialist Physician). Proposed Solutions Screening and Passenger Assessment Integrated web-based platforms, AI symptom detection, QR code self-reporting, enhanced training, improved airline collaboration “We need integrated, web-based platforms for real-time data sharing, combined with AI to detect symptoms and QR code self-reporting for passengers.” (Participant 8, IT Specialist). Isolation and Quarantine Management Dedicated ventilated isolation units, multidisciplinary quarantine teams, strengthened legal frameworks, government support for quarantine costs “Dedicated, well-ventilated isolation units staffed by multidisciplinary teams would improve quarantine management.” (Participant 10, Head, Infectious Diseases Group). Contact Tracing and Follow-Up Privacy-compliant digital platforms, formal interagency agreements, integrated flight and health data systems “Establishing a unified, web-based platform accessible to all relevant agencies would enable rapid identification and follow-up of contacts.” (Participant 8, IT Specialist). “Automated notification systems, such as SMS alerts or mobile app push notifications, can improve timely communication with exposed passengers.” (Participant 9, Health Education Specialist) Passenger Awareness and Communication Multilingual digital tools (SMS, apps, QR codes), pre-travel awareness campaigns, unified and coordinated messaging “Multilingual digital communication tools and pre-travel awareness campaigns should be launched to improve passenger cooperation.” (Participant 9, Health Education Specialist). Human Resources and Training Ongoing comprehensive training, psychological support programs, incentive and recognition systems “Continuous staff training and psychological support programs are vital to improve motivation and competence.” (Participant 3, Head, Airport Border, Ministry of Health). Legal and Organizational Frameworks Legal reforms clarifying data use and enforcement, multisectoral coordination committees, updated practical protocols, strengthening alignment with international health regulations and WHO guidelines “Legal reforms clarifying enforcement powers and data privacy, alongside formal interagency agreements, are key.” (Participant 12, Infectious Disease Specialist Physician). Fishbone analysis identified five major categories of root causes: human, technical, organizational, legal, and environmental factors (Fig. 1 ). Key human factors included lack of specialized training, low staff motivation, poor cooperation from flight crews and passengers, and behavioral resistance. Technical barriers involved inaccurate temperature devices, ineffective paper forms, and absence of integrated electronic systems. Organizational issues included poor coordination, outdated protocols, and unsuitable airport environments. Legal challenges stemmed from limited data access and weak quarantine enforcement frameworks. Environmental and operational factors such as limited screening time, passenger crowding, poor ventilation, and insufficient isolation spaces also negatively affected process quality. 4. Discussion This qualitative study revealed that COVID-19 screening and management at air border crossings in Iran face a complex, multifaceted set of challenges spanning human resources, technology, organizational coordination, infrastructure, behavior, legal frameworks, communication, and financial support. Such complexity necessitates a comprehensive, integrated, and multisectoral approach to enhance the effectiveness of border health measures. A major barrier identified was the shortage of specialized personnel, inadequate continuous training, and low staff motivation, which directly affect screening quality. This aligns with WHO (2016), which emphasizes a skilled and well-supported workforce as fundamental to effective health crisis responses( 28 ). Studies such as Shanafelt et al. (2020) highlight the importance of psychological support and workload management to prevent burnout and errors ( 29 ). Participants underscored the need for ongoing education, mental health support, and incentive systems for frontline staff. Technological limitations, including insufficient advanced equipment and inefficient information systems, hampered rapid detection, data management, and case tracking. This corroborates findings by Vaishya et al. (2020) and Subramanian et al. (2022) on the critical role of AI, digital tracking, and rapid diagnostic tools in disease control ( 30 , 31 ). Singapore’s TraceTogether app exemplifies how advanced technology improves contact tracing accuracy and timeliness ( 18 ). However, financial and infrastructural constraints in Iran limit widespread adoption, calling for targeted investment. Technological challenges, data privacy, and protection of personal information remain critical concerns globally. The integration of emerging technologies such as blockchain, combined with robust legal frameworks, is vital to address these concerns ( 17 ). Adoption of WHO recommendations on digital health certificates and vaccine passports, along with digital health diplomacy efforts, can enhance international collaboration and trust ( 17 , 25 ). Poor interagency coordination, lack of unified strategies, and inadequate legal frameworks further reduced process efficiency. This echoes Kickbusch et al. (2012), who advocate for multisectoral governance and coordinated collaboration in global health crises ( 32 ). South Korea’s experience demonstrates the effectiveness of national crisis committees and cross-sector planning ( 33 ). Interviewees highlighted the need for clear roles, responsibility delineation, legal reforms, organizational restructuring, and strengthened oversight. Furthermore, coordinated policy-making at international and regional levels, including information sharing and mutual learning, enhances border health management efficacy ( 22 , 25 ). China’s experiences with SARS and COVID-19 illustrate how centralized governance and political will can yield rapid responses but also reveal the limitations and need for international cooperation and health diplomacy ( 21 ). Consistent with international frameworks, particularly the International Health Regulations (IHR 2005) and its recent updates, border management during public health emergencies requires a delicate balance between safeguarding public health and minimizing unnecessary interference with international traffic and trade ( 7 , 25 , 34 ). Our findings highlight that gaps in intersectoral coordination, unclear legal frameworks, and insufficient technological infrastructure are major obstacles to achieving this balance. Prior research, including the typology of cross-border health measures, demonstrates that the absence of standardized definitions and coordinated practices globally has led to confusion and inefficiencies during COVID-19 ( 22 ). Environmental factors such as unsuitable spaces, inadequate ventilation, and crowding at entry points increased transmission risks. These findings align with Morawska & Milton (2020) and Dietz et al. (2020), underscoring the importance of proper ventilation, safe environmental design, and passenger flow management to mitigate airborne spread ( 20 , 35 ). Operational challenges included lack of dedicated screening and quarantine areas and poor ventilation. Infrastructure improvements incorporating well-ventilated isolation spaces and smart passenger flow technologies are vital. Behavioral and cultural factors significantly influenced screening success. Passenger resistance to protocols, misinformation, and linguistic and cultural diversity impeded full cooperation. Literature by Betsch et al. (2020) and Van Bavel et al. (2020) confirms that targeted, participatory cultural interventions substantially increase public compliance ( 14 , 36 ). Interviewees emphasized multilingual messaging, diverse media use, trust-building, and ensuring passenger rights and support during quarantine to reduce behavioral resistance. Multiple studies indicate that social inequalities, cultural diversity, and population attitudes profoundly influence the acceptance and implementation of border health measures. Resistance from travelers, misinformation, and privacy concerns are significant barriers that cannot be overcome without culturally sensitive and participatory approaches involving community engagement ( 17 , 22 , 37 ). Legal ambiguities regarding data privacy, organizational responsibilities, and authorities posed significant challenges. Gostin et al. (2019) identify such legal gaps as major weaknesses in global health crisis management ( 38 ). Lack of coherent legislation caused enforcement ambiguities and privacy concerns. Precise legal frameworks, staff legal training, and judicial cooperation are essential for effective regulation. Fragmented communication, inconsistent messaging, and limited use of modern information technologies reduced process effectiveness. This agrees with Lowe et al. (2022) and Nan et al. (2022), highlighting the role of timely, transparent, and multilingual communication in fostering public cooperation ( 39 , 40 ). Successful countries use centralized digital communication platforms, which could serve as models. Participants stressed pre-travel information dissemination and feedback channels. Financial and economic constraints permeated all aspects of screening, hindering infrastructure development, expert recruitment, and advanced technology use. Experiences from Sweden and Canada show that sustainable funding and private sector involvement optimize resources and service quality ( 41 , 42 ). Interviewees identified financial shortages as a critical barrier, underscoring the need for government support and economic facilitation for quarantined travelers. This study has several limitations. As a qualitative study using semi-structured interviews, recall and social desirability biases may have affected participants’ responses and limited disclosure of sensitive information. Focusing only on air border crossings excludes land and sea ports, limiting generalizability. Cultural, economic, and infrastructural differences further restrict the applicability of results to other countries with different health systems or governance. Limited access to official documents and strict security measures limited contextual analysis and observation. The long time since the pandemic peak may have reduced the immediacy and accuracy of findings. Finally, despite purposive sampling, the small sample size may not capture all perspectives, affecting the comprehensiveness of issues and solutions. Future research should examine border health measures at land and sea crossings to complement findings from airports. Studies conducted closer to pandemic peaks are needed to better capture real-time challenges. Quantitative and comparative research across different cultural and economic contexts can improve generalizability. Additionally, evaluating the role of digital technologies and reviewing relevant regulations in border settings may enhance pandemic response effectiveness. 5. Conclusion This study examines challenges in COVID-19 screening and management at Iran’s air border crossings. Key issues include inadequate human resources, technological limitations, poor organizational coordination, legal gaps, and environmental factors, which hinder effective border health measures and compliance with International Health Regulations. Proposed solutions, such as integrated digital platforms, enhanced staff training, improved quarantine facilities, and clearer legal mandates, are based on participants’ insights. Successful implementation will require ongoing multisectoral collaboration and resource allocation. Overall, the findings highlight the complexity of border health management during pandemics and the need for alignment with international frameworks to improve pandemic response. Abbreviations COREQ Consolidated Criteria for Reporting Qualitative Research PCR Polymerase Chain Reaction IT Information Technology AI Artificial Intelligence WHO World Health Organization Declarations Ethics approval and consent to participate All participants voluntarily consented after being informed about study objectives and data usage. Confidentiality and anonymity were strictly maintained. This study was conducted in accordance with ethical standards, and ethical approval was obtained from the relevant committee (Code: 1402.135REC.PHNS.SBMU.IR). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by Shahid Beheshti University of Medical Sciences under grant number 43013183. This study was conducted as part of a Ph.D. thesis at the School of Public Health and Safety, Shahid Beheshti University of Medical Sciences. The funding body had no role in study design, data collection, analysis, interpretation, or manuscript preparation. This study is obtained from a Ph.D. thesis at School of Public Health and Safety. Authors' contributions MK and HP conceptualized the study. The literature search was conducted by HP and MG. Data collection, including conducting interviews, was carried out by HP, AN, and AK. Data analysis and initial drafting of the manuscript were performed by HP, AN, MG and AK. MK provided critical revisions to the manuscript. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgments We would like to express our sincere gratitude to all individuals and organizations that contributed to the completion of this study. We especially thank the participants who generously shared their time, expertise, and insights. We also appreciate the support of the staff at the border health base during the field visit, whose cooperation was invaluable. Finally, we acknowledge the guidance and feedback from our academic mentors and colleagues throughout the research process. Authors' information HP PhD Candidate at Shahid Beheshti University of Medical Sciences, Tehran. His research focuses on infectious diseases, with interests in their management, control, and informing health policy to improve public health outcomes. MG Public Health expert at Shahid Beheshti University of Medical Sciences, specializing in health education and promotion. Committed to advancing public health management and supporting health policymakers in addressing community health challenges. AN MD-MPH working in the Deputy of Health at Tehran University of Medical Sciences. Responsible for controlling and managing communicable diseases, focusing on public health management and policy implementation for infectious disease control. AK Biostatistician at Shahid Beheshti University of Medical Sciences collaborating with epidemiologists. Research interests include health determinants and providing statistical support to health policymakers and decision-makers. MK Professor of Epidemiology at Shahid Beheshti University of Medical Sciences and affiliated with the Ministry of Health, Iran. His work centers on infectious disease control, management, and promoting effective health policies. 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INQUIRY: J Health Care Organ Provis Financing. 2022;59:00469580221084185. Ishikawa K. Guide to quality control. 1982. World Health Organization. Health workforce requirements for universal health coverage and the sustainable development goals.(human resources for health observer, 17). Health workforce requirements for universal health coverage and the Sustainable Development Goals(Human Resources for Health Observer, 17)2016. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133–4. Subramanian N, Elharrouss O, Al-Maadeed S, Chowdhury M. A review of deep learning-based detection methods for COVID-19. Comput Biol Med. 2022;143:105233. Vaishya R, Javaid M, Khan IH, Haleem A. Artificial Intelligence (AI) applications for COVID-19 pandemic. Diabetes Metabolic Syndrome: Clin Res Reviews. 2020;14(4):337–9. Kickbusch I, Gleicher DE. Governance for health in the 21st century. 2012. You J. Lessons from South Korea’s Covid-19 policy response. Am Rev Public Adm. 2020;50(6–7):801–8. Khankeh H, Farrokhi M, Roudini J, Pourvakhshoori N, Ahmadi S, Abbasabadi-Arab M, et al. Challenges to manage pandemic of coronavirus disease (COVID-19) in Iran with a special situation: a qualitative multi-method study. BMC Public Health. 2021;21(1):1919. Morawska L, Milton DK. It is time to address airborne transmission of COVID-19. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2020:ciaa939. Betsch C, Korn L, Sprengholz P, Felgendreff L, Eitze S, Schmid P et al. Social and behavioral consequences of mask policies during the COVID-19 pandemic. Proceedings of the National Academy of Sciences. 2020;117(36):21851-3. Cai S, Zhang T, Robin C, Sawyer C, Rice W, Smith LE, et al. Learning about COVID-19 across borders: public health information and adherence among international travellers to the UK. Public Health. 2022;203:9–14. Gostin LO, Monahan JT, Kaldor J, DeBartolo M, Friedman EA, Gottschalk K, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. lancet. 2019;393(10183):1857–910. Lowe M, Harmon SH, Kholina K, Parker R, Graham JE. Public health communication in Canada during the COVID-19 pandemic. Can J Public Health. 2022;113(Suppl 1):34–45. Nan X, Iles IA, Yang B, Ma Z. Public health messaging during the COVID-19 pandemic and beyond: Lessons from communication science. Health Commun. 2022;37(1):1–19. Ludvigsson JF. How Sweden approached the COVID-19 pandemic: Summary and commentary on the National Commission Inquiry. Acta Paediatr. 2023;112(1):19–33. Gosselin JS, Godbout L, Gagné-Dubé T, St-Cerny S. The economic response of governments in Canada to COVID-19 in the First Three months of the Crisis. Can Tax J. 2020;68:863. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Apr, 2026 Read the published version in Globalization and Health → Version 1 posted Editorial decision: Revision requested 23 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviewers agreed at journal 18 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers invited by journal 08 Jan, 2026 Editor assigned by journal 01 Dec, 2025 Submission checks completed at journal 03 Nov, 2025 First submitted to journal 01 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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07:51:54","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":137166,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7674653/v1/94bdd8fe08e2f05eca9141d6.html"},{"id":100047657,"identity":"dd96baa9-3f2b-43df-a8fe-167d9511cc01","added_by":"auto","created_at":"2026-01-12 12:25:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":161974,"visible":true,"origin":"","legend":"\u003cp\u003eChallenges and Barriers to Effective COVID-19 Screening at Iran’s Air Border Crossings using fish-bone analysis framework\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7674653/v1/3f195c3b2b4ae5c0a16fc586.jpg"},{"id":107352188,"identity":"7d6f6699-8a62-459a-be69-3ef1d738379d","added_by":"auto","created_at":"2026-04-20 16:13:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":723321,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7674653/v1/b3252180-45fa-4f27-af46-7c636d940b02.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges and Barriers to Effective COVID-19 Screening at Iran’s Air Border Crossings: A Qualitative Study and Proposed Solutions","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEmerging and re-emerging respiratory viral diseases with high transmissibility, such as COVID-19, seasonal and pandemic influenza, SARS, and MERS, have posed major challenges to health systems worldwide, particularly at international border points (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The rapid global spread of COVID-19 since late 2019 has highlighted the critical role of international borders, especially air border crossings, as frontline defense points in preventing cross-border transmission of infectious diseases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Effective screening and management at these points are essential not only for national public health security but also for global health security, in line with the objectives set by the World Health Organization\u0026rsquo;s International Regulations (IHR 2005) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe IHR framework mandates countries to develop and maintain core capacities at points of entry, including airports, to detect, assess, report, and respond to public health emergencies of international concern (PHEIC). Recent revisions and updates to the IHR emphasize enhanced surveillance, real-time data sharing, and multisectoral coordination to strengthen border health management during pandemics (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Given the transnational nature of respiratory pandemics, failures or gaps in border screening can have significant repercussions beyond national boundaries, underscoring the importance of aligning local practices with global regulations and standards.\u003c/p\u003e \u003cp\u003eAir border points play a pivotal role in preventing the entry of suspected or confirmed cases and thus are central to infection control policies. Screening methods at these sites typically include self-reporting, vital sign monitoring (e.g., fever), rapid molecular or antigen testing, as well as quarantine and contact tracing procedures (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The effectiveness of these measures directly influences viral spread within communities by preventing new case introductions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite their importance, screening processes at airports face multiple challenges that undermine their effectiveness. Key obstacles include shortages of trained personnel, inefficient technologies and information systems, poor organizational coordination, inadequate infrastructure, and financial constraints (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Additionally, travelers\u0026rsquo; behavioral and cultural factors, such as resistance to health protocols, misinformation, and lack of awareness, significantly affect control efforts (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobal experiences during the COVID-19 pandemic demonstrate that leveraging advanced technologies such as digital health platforms, artificial intelligence, and integrated data systems can substantially improve the effectiveness of border health measures (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Countries like South Korea and Singapore have showcased successful models of data-driven, coordinated border screening and contact tracing, contributing to rapid containment of viral spread (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Furthermore, appropriate environmental infrastructure and optimal ventilation in airport spaces are recognized as important factors in reducing respiratory disease transmission (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Moreover, challenges such as legal and ethical issues related to data privacy, passenger compliance, and interagency coordination have emerged as common barriers worldwide, necessitating comprehensive policy responses within the global health governance framework (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the global importance of these issues, there remains limited in-depth qualitative research focusing on operational challenges and contextual barriers faced by countries like Iran in implementing effective COVID-19 screening at air borders (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Iran was among the early countries to experience imported COVID-19 cases. Iran\u0026rsquo;s unique social, cultural, economic, and infrastructural contexts, combined with its significant passenger traffic and geopolitical position, present both challenges and opportunities for improving border health management in ways that can inform global policy discourse (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Moreover, insufficient attention to behavioral and cultural dimensions, weak inter-organizational coordination, and legal complexities regarding data privacy have been identified as key barriers needing resolution in operational settings (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, this study aims to identify and analyze the challenges, barriers, and proposed solutions related to COVID-19 screening and management at Iran\u0026rsquo;s air border crossings, while situating these findings within the broader context of international health regulations and global pandemic response strategies. By integrating qualitative insights with a review of global scientific literature, this research seeks to contribute to the understanding of how national-level experiences can inform and be informed by global-level health security frameworks, supporting evidence-based policy-making in pandemic preparedness and responses.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Approach:\u003c/h2\u003e \u003cp\u003eThis qualitative study employed a content analysis approach to examine COVID-19 screening and management processes at Iran\u0026rsquo;s air border crossings, aiming to identify challenges and improvement opportunities. The qualitative method was chosen for its ability to deeply explore experiences and perspectives of key stakeholders. In addition to primary qualitative data collection, a comprehensive review of international health regulations, including the International Health Regulations (IHR 2005) and recent updates, as well as global pandemic response literature, was conducted to frame the analysis within global health governance and policy contexts. This dual approach ensures that the study\u0026rsquo;s findings not only reflect national realities but also contribute to international policy discourse [The details of the methodology, along with a review of global guidelines and scientific literature, are presented in a Ph.D. thesis by HP, titled \u0026ldquo;Development and Local Adaptation of a Screening Method and Management of Acute Respiratory Viral Infections in Aerial Entry Points\u0026rdquo;, at the School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Iran]. This study was conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure rigor and transparency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Population and Sampling:\u003c/h2\u003e \u003cp\u003eThe target population included key experts involved in border health management, airport healthcare, infectious disease control, and crisis management at Iran\u0026rsquo;s air borders. Participants were recruited through official channels and professional networks, ensuring representation of diverse stakeholder roles, and with a response rate of 80%. Participants comprised border health managers, infectious disease specialists, airport healthcare providers, IT experts related to health systems, and airline representatives. Purposive sampling was used to select individuals with practical experience and expertise in COVID-19 screening and management at airports. Eligibility criteria required at least five years of relevant experience, involvement in border health programs, and willingness to participate. Sampling continued until data saturation was reached, achieved after twelve interviews.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection:\u003c/h2\u003e \u003cp\u003eSemi-structured interviews, guided by open-ended questions, explored various aspects including pre-travel, airport, and post-entry screening processes; screening tools and technologies; isolation and quarantine procedures; contact tracing and case management; training and awareness for passengers and staff; existing challenges; and suggestions for improvement. The open-ended format allowed themes to emerge naturally from participants\u0026rsquo; responses. The interview guide (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) included main questions on challenges, barriers, and solutions, accompanied by probing questions to deepen the discussion. The interview guide was developed through a systematic process to ensure clarity, relevance, and comprehensiveness. Initially, a draft guide was created based on the study objectives, relevant literature on COVID-19 border health management, and input from subject matter experts in infectious diseases and public health. To enhance validity and practicality, the draft interview guide was pilot-tested with two healthcare professionals experienced in border screening but not involved in the main study. Feedback from these pilot interviews focused on question clarity, flow, and comprehensiveness. Based on pilot results, ambiguous or leading questions were revised, and additional probes were incorporated to elicit more in-depth responses. The guide was iteratively refined to balance open-ended questions that encourage rich narratives with focused prompts aligned to the study\u0026rsquo;s thematic areas.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview Questionnaire: Open-Ended Questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain Questions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProbing Questions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChallenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Can you describe the main challenges you have encountered in the COVID-19 screening process at the air border?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Could you give specific examples of when these challenges occurred?\u003c/p\u003e \u003cp\u003e- How do these challenges affect your daily work or overall process effectiveness?\u003c/p\u003e \u003cp\u003e- Are these challenges related to resources, procedures, or people?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. What difficulties have you noticed in managing isolation and quarantine for travelers?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- How adequate are the current facilities and resources for quarantine?\u003c/p\u003e \u003cp\u003e- Have you faced any issues with compliance or enforcement?\u003c/p\u003e \u003cp\u003e- What factors contribute most to these difficulties?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. What obstacles exist regarding contact tracing of passengers who may have been exposed to COVID-19?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Are there any technical or organizational barriers to accessing or sharing information?\u003c/p\u003e \u003cp\u003e- How timely is the contact tracing process in practice?\u003c/p\u003e \u003cp\u003e- What are the main causes of delay or failure in tracing contacts?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. How effective do you find the communication and awareness efforts directed at passengers?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- What communication methods are used?\u003c/p\u003e \u003cp\u003e- Are passengers generally cooperative and well-informed?\u003c/p\u003e \u003cp\u003e- What challenges do you face in reaching diverse passenger groups?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. What challenges do staff face in carrying out their responsibilities related to COVID-19 screening and management?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- How sufficient is the training and support for staff?\u003c/p\u003e \u003cp\u003e- Are there issues related to motivation, workload, or coordination?\u003c/p\u003e \u003cp\u003e- How do staff perceive their roles and responsibilities?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. What legal or organizational challenges affect the COVID-19 management process at the border?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Are there clear policies and regulations in place?\u003c/p\u003e \u003cp\u003e- How well do different organizations coordinate and communicate?\u003c/p\u003e \u003cp\u003e- Have you experienced any conflicts or gaps in authority?\u003c/p\u003e \u003cp\u003e- How does your organization incorporate or comply with international regulations such as the International Health Regulations (IHR 2005) during screening and management?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuggested Solutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. In your opinion, what changes or improvements could help overcome the challenges you mentioned?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Are there specific technologies or systems that could be introduced or improved?\u003c/p\u003e \u003cp\u003e- what role do you think alignment with global health guidelines and frameworks plays in improving border health management?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. How could the infrastructure for isolation and quarantine be improved?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- What resources or facilities are currently lacking?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. What steps could be taken to improve the contact tracing process?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- How can data sharing and interagency cooperation be enhanced?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. What strategies would you recommend to enhance passenger awareness and communication?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. What legal or policy reforms do you think are necessary to support better COVID-19 management at the border?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Are there gaps or ambiguities in current regulations?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e Interviews were conducted face-to-face in a private office or by phone, based on participant preference, and with informed consent, and lasted 60\u0026ndash;80 minutes. All interviews were audio-recorded with consent and transcribed verbatim. To ensure accuracy, transcripts were cross-checked by the research team. Field notes supplemented audio recordings, capturing non-verbal cues and environmental context.\u003c/p\u003e \u003cp\u003eIn addition, a field visit to the border health base at Imam Khomeini International Airport was conducted to observe physical settings, equipment, staff deployment, and operational procedures such as sample collection and documentation, offering practical insights into current conditions.\u003c/p\u003e \u003cp\u003e\u0026lt;Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026gt;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Interviewers characteristics:\u003c/h2\u003e \u003cp\u003eInterviews were conducted by [HP /author], who is experienced qualitative researcher with backgrounds in infectious disease control and public health. The interviewer had no prior relationship with participants, minimizing potential bias. Reflexivity was maintained by documenting assumptions and discussing potential biases within the research team. Field notes were kept to capture contextual observations and interviewer impressions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Analysis:\u003c/h2\u003e \u003cp\u003eBased on the research questions, a directed content analysis approach was employed to analyze the interview transcripts. Initially, the data were systematically coded according to predefined categories aligned with the study objectives, and subsequently, categories and sub- categories were identified and organized to reflect the underlying patterns and groupings. This process was facilitated using MAXQDA software (version 24). Two researchers independently coded the transcripts. Discrepancies were resolved through discussion until consensus was reached. To deepen the understanding of the identified challenges, a root cause analysis was conducted using the Fishbone (Ishikawa) framework, categorizing causes into five main domains: human, technical, organizational, legal, and environmental factors. An audit trail documented coding decisions and theme development. This combined approach enabled a comprehensive exploration of the issues and supported the development of targeted recommendations(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Trustworthiness Measures:\u003c/h2\u003e \u003cp\u003e To enhance credibility and reliability, several strategies were employed: member checking (participants reviewed summaries and codes for accuracy), independent coding by two researchers with consensus discussions, thorough documentation of data collection and analysis procedures to ensure reproducibility, and repeated transcript reviews to ensure comprehensive and precise coding. Thick descriptions of context and participant quotes were included to enhance transferability of findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Ethical Considerations:\u003c/h2\u003e \u003cp\u003eAll participants voluntarily consented after being informed about study objectives and data usage. Confidentiality and anonymity were strictly maintained. Audio files and transcripts were securely stored on encrypted devices accessible only to the research team and will be retained for five years in accordance with institutional policy. This study was conducted in accordance with ethical standards, and ethical approval was obtained from the relevant committee (Code: 1402.135REC.PHNS.SBMU.IR).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Methodological Limitations:\u003c/h2\u003e \u003cp\u003eAlthough carefully designed, limitations include the purposive sampling and limited number of interviews, which may not capture all perspectives. Response bias is also possible. Nevertheless, validity checks employed mitigate these limitations substantially. To reduce interviewer bias, interviewers followed a standardized guide and reflected on their positionality throughout the research process.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Field visit findings:\u003c/h2\u003e \u003cp\u003eA field visit to the border health base at Imam Khomeini Airport revealed multiple operational and structural challenges in COVID-19 screening and management at Iran\u0026rsquo;s air border crossings. The most notable issue was the absence of comprehensive guidelines and cohesive educational resources, resulting in fragmented, unsystematic, and somewhat discretionary implementation of procedures.\u003c/p\u003e \u003cp\u003eAlthough basic medical equipment such as examination beds, vaccine refrigerators, and handheld thermometers were available, they were insufficient for comprehensive screening. Advanced technologies for data recording, tracking, and analysis were largely underutilized. Self-declaration forms distributed by flight crews were often incomplete and unreliable due to limited airline cooperation.\u003c/p\u003e \u003cp\u003eVaccination and test result verifications were conducted manually, sometimes using staff personal internet connections, causing delays and allowing fraudulent documentation. Sampling processes, including rapid tests and PCR, experienced significant result turnaround delays.\u003c/p\u003e \u003cp\u003eA critical shortage of specialized personnel, including doctors, nurses, and laboratory staff, placed extensive responsibilities on health monitors, adversely affecting quality. Lack of a designated authority to enforce health protocols led to poor mask use, inadequate social distancing, and insufficient ventilation in terminals, increasing transmission risk, particularly amid passenger congestion at entrances.\u003c/p\u003e \u003cp\u003eQuarantine procedures lacked defined teams and oversight frameworks; some travelers left quarantine prematurely due to incomplete follow-up or intermediaries, revealing weaknesses in enforcement.\u003c/p\u003e \u003cp\u003e Overall, the field visit emphasized the need for structural reforms, enhanced IT infrastructure, strengthened specialist workforce, expanded training and awareness, and comprehensive, practical guidelines to improve screening and disease management at air borders.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Interview Findings:\u003c/h2\u003e \u003cp\u003eTwelve stakeholders participated in semi-structured interviews, were interviewed between Mar and Nov 2024. The Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the demographic and professional profiles of study participants. Participants were interviewed, including 9 males and 3 females, with ages ranging from 38 to 62 years. Their professional experience in relevant fields ranged from 7 to 20 years (mean\u0026thinsp;=\u0026thinsp;15 years). Pseudonyms (e.g., P1, P2) are used to maintain confidentiality in reporting quotes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and professional profiles of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpertise and Educational Degree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosition/Role\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYears of Experience\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of Epidemiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead of Border Health Department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of Epidemiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoordinator, Health Ministry \u0026amp; Border Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD, MPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead, Airport Border, Ministry of Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMSc in Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAirport Border Healthcare Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBSc in Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBorder Health Screening Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of Epidemiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInfectious Disease Epidemiologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of Epidemiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVital Statistics Specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of IT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIT Specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh.D. of Health Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth Education Specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD, MPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead, Infectious Diseases Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMSc in HSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAirport Safety Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInfectious Disease Specialist Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis of interviews revealed multiple, interrelated challenges affecting the effectiveness of COVID-19 screening and management at Iran\u0026rsquo;s air border crossings. One of the main challenges concerns the screening and passenger assessment processes. While protocols such as syndromic evaluations, temperature checks, and self-report forms are in place, their implementation is often inconsistent and fragmented. This inconsistency stems from unclear or outdated guidelines specific to air border contexts and is compounded by poor coordination between airlines, airport staff, and health authorities. The reliance on paper-based self-report forms, which are frequently incomplete or inaccurately filled, reflects both limited passenger cooperation and weak airline engagement. Moreover, technological limitations, including insufficient availability of advanced screening devices and lack of integrated digital data systems, hamper efficient case identification and monitoring. Behavioral resistance from passengers, driven by fears of quarantine or stigma, further reduces the accuracy and reliability of screening efforts. Additionally, the shortage of well-trained and motivated personnel exacerbates these issues, as staff often lack continuous education and adequate support to maintain high-quality assessments.\u003c/p\u003e \u003cp\u003eIsolation and quarantine management present another significant challenge. The existing physical infrastructure is inadequate, with a shortage of properly ventilated and equipped isolation spaces within airports. The absence of multidisciplinary teams responsible for clinical care and quarantine monitoring results in inconsistent enforcement and follow-up. Legal ambiguities and weak enforcement mechanisms limit authorities\u0026rsquo; ability to mandate quarantine, causing some travelers to prematurely leave isolation areas. The overcrowding of terminal spaces combined with poor ventilation increases the risk of in-terminal transmission. Furthermore, foreign travelers bear the financial burden of hotel quarantine without sufficient oversight, which sometimes undermines compliance. These factors collectively weaken the effectiveness of isolation measures crucial for controlling disease spread.\u003c/p\u003e \u003cp\u003eContact tracing efforts are hindered by restricted access to passenger data, largely due to privacy laws and fragmented interagency cooperation. Without standardized communication protocols and integrated data-sharing platforms, contact tracing remains manual, delayed, and incomplete. The lack of cooperation from airlines and other stakeholders further complicates timely identification and follow-up of potential contacts.\u003c/p\u003e \u003cp\u003ePassenger awareness and sensitization efforts primarily rely on traditional communication methods such as banners and pamphlets. Given passengers\u0026rsquo; short transit times and the linguistic and cultural diversity of travelers, these methods have limited effectiveness. Fragmented messaging, resulting from weak collaboration among health authorities, airport management, and airlines, further diminishes the impact of awareness campaigns.\u003c/p\u003e \u003cp\u003eHuman resource constraints represent a cross-cutting barrier influencing many operational aspects. There is a notable shortage of specialized and adequately trained personnel to conduct screening, manage quarantine, and perform follow-up activities. Staff motivation is often low due to repetitive tasks, insufficient psychological support, and lack of incentives, all contributing to reduced quality and consistency of interventions.\u003c/p\u003e \u003cp\u003eFinally, legal and organizational frameworks are characterized by ambiguities and gaps. The absence of clear policies regarding data privacy, quarantine enforcement, and defined interagency roles results in fragmented responsibilities and poor coordination. Without strong legal backing and multisectoral governance mechanisms, implementation of health protocols becomes inconsistent and ineffective.\u003c/p\u003e \u003cp\u003e Several participants highlighted the challenges in fully implementing the International Health Regulations (IHR 2005) core capacities at air border crossings. They emphasized the need for clearer legal mandates, standardized protocols aligned with WHO recommendations, and enhanced multisectoral and interagency coordination to meet global health security requirements. These gaps affect not only national pandemic response effectiveness but also Iran\u0026rsquo;s compliance with international obligations during Public Health Emergencies of International Concern (PHEIC).\u003c/p\u003e \u003cp\u003eTo address these interconnected challenges and underlying barriers, stakeholders proposed a range of solutions. These include the development of integrated, web-based digital platforms that enable real-time data sharing and monitoring across agencies. Advanced technologies such as artificial intelligence for symptom detection and QR code-based self-reporting were recommended to enhance screening accuracy and passenger compliance. Strengthening staff training programs, including continuous education and psychological support, was emphasized to improve workforce capacity and motivation. Enhancing collaboration with airlines ensures better engagement and data completeness. The establishment of dedicated, well-ventilated isolation and quarantine facilities staffed by multidisciplinary teams would improve management and enforcement. Legal reforms to clarify enforcement powers, data privacy, and interagency roles, alongside formal agreements to foster cooperation, were identified as essential. Additionally, launching targeted, multilingual pre-travel awareness campaigns and employing modern digital communication tools would improve passenger sensitization and adherence to health protocols. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the summary of challenges, barriers, and proposed solutions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Challenges, Barriers, and Proposed Solutions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes (Key Concepts)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eChallenges \u0026amp; Barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening and Passenger Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncomplete self-report forms, inconsistent protocol application, limited technology use, poor coordination, passenger behavioral resistance, inadequate training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipants reported inconsistent application of protocols and incomplete self-report forms as major obstacles. \u0026ldquo;Many passengers do not fill the forms properly, and we have limited technology to verify their answers,\u0026rdquo; explained P3 (Head, Airport Border, Ministry of Health).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes the guidelines change frequently, and we don\u0026rsquo;t get timely updates, so each shift applies different rules.\u0026rdquo; (Participant 4, Airport Healthcare Officer).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes the thermal scanners were removed, and manual temperature checks were used, but these are not very reliable, especially for acute respiratory diseases. Environmental factors and passenger movement affect accuracy.\u0026rdquo; (Participant 1, Head of Border Health Department).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Flight crews distributed self-declaration forms, but many were incomplete or passengers wrote unrelated notes. Cooperation from airlines was insufficient.\u0026rdquo; (Participant 5, Border Health Screening Staff)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Passengers are often in a hurry, worried about their luggage or family, and reluctant to cooperate fully with screening.\u0026rdquo; (Participant 1, Head of Border Health Department)\u003c/p\u003e \u003cp\u003e\u0026ldquo;We had no integrated digital system; verifications of vaccinations or test results were done manually, sometimes even using staff personal internet connections, leading to delays and allowing fraudulent documents.\u0026rdquo; (Participant 5, Border Health Screening Staff).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolation and Quarantine Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsufficient isolation facilities, lack of specialized teams, weak legal enforcement, overcrowded and poorly ventilated spaces, financial burden on travelers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;We lack enough well-ventilated isolation rooms, and the enforcement of quarantine is weak due to legal gaps,\u0026rdquo; noted P6 (Infectious Disease Epidemiologist).\u003c/p\u003e \u003cp\u003e\u0026ldquo;There was no proper isolation space at the airport; some travelers left quarantine early due to poor follow-up and lack of enforcement.\u0026rdquo; (Participant 5, Border Health Screening Staff).\u003c/p\u003e \u003cp\u003e\u0026ldquo;We can educate families about quarantine, but strict enforcement is lacking because of unclear laws. A traveler can easily leave quarantine without consequences.\u0026rdquo; (Participant 10, Head of Border Health Department).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Foreign travelers bear the cost of hotel quarantine, which affects their willingness to comply strictly.\u0026rdquo; (Participant 5, Border Health Screening Staff)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContact Tracing and Follow-Up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRestricted data access due to privacy laws, fragmented interagency cooperation, manual and delayed data processing, lack of standardized communication channels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Access to passenger data is restricted by privacy laws, and cooperation between agencies is limited, which delays tracing,\u0026rdquo; stated P8 (IT Specialist).\u003c/p\u003e \u003cp\u003e\u0026ldquo;We sometimes received advance emails listing passengers exposed to cases, but immediate follow-up at the airport was difficult due to legal and logistical barriers.\u0026rdquo; (Participant 1, Head of Border Health Department).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Without integrated systems and formal agreements, contact tracing remains manual and slow.\u0026rdquo; (Participant 8, IT Specialist).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassenger Awareness and Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited impact of traditional methods, short transit time, linguistic and cultural diversity, fragmented messaging, weak intersectoral collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Traditional methods like banners are not very effective given the short transit time and language barriers,\u0026rdquo; remarked P9 (Health Education Specialist).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Passengers are often too busy or distracted to engage with health messages. We need to use modern technologies like mobile notifications with links to health info.\u0026rdquo; (Participant 1, Head of Border Health Department).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Different authorities send different messages; there is no unified communication strategy.\u0026rdquo; (Participant 9, Health Education Specialist).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHuman Resources and Training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStaff shortages, insufficient continuous education, low motivation, burnout, lack of psychological support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Staff are overworked and lack ongoing training, which affects motivation and performance,\u0026rdquo; commented P5 (Border Health Screening Staff).\u003c/p\u003e \u003cp\u003e\u0026ldquo;There is a shortage of doctors and nurses; health monitors bear excessive responsibilities, leading to burnout and inconsistent quality.\u0026rdquo; (Participant 5, Border Health Screening Staff).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Staff often work just to fulfill minimum duties. Lack of incentives and recognition reduces enthusiasm.\u0026rdquo; (Participant 3, Head, Airport Border, Ministry of Health).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLegal and Organizational Frameworks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmbiguous data privacy laws, weak quarantine enforcement policies, unclear interagency roles, poor coordination among stakeholders, incomplete implementation of International Health Regulations (IHR 2005)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;There is confusion about roles and responsibilities, and no strong legal backing for quarantine enforcement,\u0026rdquo; emphasized P2 (Coordinator, Health Ministry \u0026amp; Border Care).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Legal frameworks are vague; quarantine enforcement is weak, and no single agency has clear authority.\u0026rdquo; (Participant 1, Head of Border Health Department).\u003c/p\u003e \u003cp\u003e\u0026ldquo;A unified management structure and legal reforms are essential to empower enforcement and data sharing.\u0026rdquo; (Participant 12, Infectious Disease Specialist Physician).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eProposed Solutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening and Passenger Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntegrated web-based platforms, AI symptom detection, QR code self-reporting, enhanced training, improved airline collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;We need integrated, web-based platforms for real-time data sharing, combined with AI to detect symptoms and QR code self-reporting for passengers.\u0026rdquo; (Participant 8, IT Specialist).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolation and Quarantine Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDedicated ventilated isolation units, multidisciplinary quarantine teams, strengthened legal frameworks, government support for quarantine costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Dedicated, well-ventilated isolation units staffed by multidisciplinary teams would improve quarantine management.\u0026rdquo; (Participant 10, Head, Infectious Diseases Group).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContact Tracing and Follow-Up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivacy-compliant digital platforms, formal interagency agreements, integrated flight and health data systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Establishing a unified, web-based platform accessible to all relevant agencies would enable rapid identification and follow-up of contacts.\u0026rdquo; (Participant 8, IT Specialist).\u003c/p\u003e \u003cp\u003e\u0026ldquo;Automated notification systems, such as SMS alerts or mobile app push notifications, can improve timely communication with exposed passengers.\u0026rdquo; (Participant 9, Health Education Specialist)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassenger Awareness and Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultilingual digital tools (SMS, apps, QR codes), pre-travel awareness campaigns, unified and coordinated messaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Multilingual digital communication tools and pre-travel awareness campaigns should be launched to improve passenger cooperation.\u0026rdquo; (Participant 9, Health Education Specialist).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHuman Resources and Training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOngoing comprehensive training, psychological support programs, incentive and recognition systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Continuous staff training and psychological support programs are vital to improve motivation and competence.\u0026rdquo; (Participant 3, Head, Airport Border, Ministry of Health).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLegal and Organizational Frameworks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLegal reforms clarifying data use and enforcement, multisectoral coordination committees, updated practical protocols, strengthening alignment with international health regulations and WHO guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Legal reforms clarifying enforcement powers and data privacy, alongside formal interagency agreements, are key.\u0026rdquo; (Participant 12, Infectious Disease Specialist Physician).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026lt;Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026gt;\u003c/p\u003e \u003cp\u003eFishbone analysis identified five major categories of root causes: human, technical, organizational, legal, and environmental factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Key human factors included lack of specialized training, low staff motivation, poor cooperation from flight crews and passengers, and behavioral resistance. Technical barriers involved inaccurate temperature devices, ineffective paper forms, and absence of integrated electronic systems. Organizational issues included poor coordination, outdated protocols, and unsuitable airport environments. Legal challenges stemmed from limited data access and weak quarantine enforcement frameworks. Environmental and operational factors such as limited screening time, passenger crowding, poor ventilation, and insufficient isolation spaces also negatively affected process quality.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u0026lt;Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026gt;\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis qualitative study revealed that COVID-19 screening and management at air border crossings in Iran face a complex, multifaceted set of challenges spanning human resources, technology, organizational coordination, infrastructure, behavior, legal frameworks, communication, and financial support. Such complexity necessitates a comprehensive, integrated, and multisectoral approach to enhance the effectiveness of border health measures.\u003c/p\u003e \u003cp\u003eA major barrier identified was the shortage of specialized personnel, inadequate continuous training, and low staff motivation, which directly affect screening quality. This aligns with WHO (2016), which emphasizes a skilled and well-supported workforce as fundamental to effective health crisis responses(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Studies such as Shanafelt et al. (2020) highlight the importance of psychological support and workload management to prevent burnout and errors (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Participants underscored the need for ongoing education, mental health support, and incentive systems for frontline staff.\u003c/p\u003e \u003cp\u003eTechnological limitations, including insufficient advanced equipment and inefficient information systems, hampered rapid detection, data management, and case tracking. This corroborates findings by Vaishya et al. (2020) and Subramanian et al. (2022) on the critical role of AI, digital tracking, and rapid diagnostic tools in disease control (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Singapore\u0026rsquo;s TraceTogether app exemplifies how advanced technology improves contact tracing accuracy and timeliness (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, financial and infrastructural constraints in Iran limit widespread adoption, calling for targeted investment. Technological challenges, data privacy, and protection of personal information remain critical concerns globally. The integration of emerging technologies such as blockchain, combined with robust legal frameworks, is vital to address these concerns (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Adoption of WHO recommendations on digital health certificates and vaccine passports, along with digital health diplomacy efforts, can enhance international collaboration and trust (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePoor interagency coordination, lack of unified strategies, and inadequate legal frameworks further reduced process efficiency. This echoes Kickbusch et al. (2012), who advocate for multisectoral governance and coordinated collaboration in global health crises (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). South Korea\u0026rsquo;s experience demonstrates the effectiveness of national crisis committees and cross-sector planning (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Interviewees highlighted the need for clear roles, responsibility delineation, legal reforms, organizational restructuring, and strengthened oversight. Furthermore, coordinated policy-making at international and regional levels, including information sharing and mutual learning, enhances border health management efficacy (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). China\u0026rsquo;s experiences with SARS and COVID-19 illustrate how centralized governance and political will can yield rapid responses but also reveal the limitations and need for international cooperation and health diplomacy (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with international frameworks, particularly the International Health Regulations (IHR 2005) and its recent updates, border management during public health emergencies requires a delicate balance between safeguarding public health and minimizing unnecessary interference with international traffic and trade (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our findings highlight that gaps in intersectoral coordination, unclear legal frameworks, and insufficient technological infrastructure are major obstacles to achieving this balance. Prior research, including the typology of cross-border health measures, demonstrates that the absence of standardized definitions and coordinated practices globally has led to confusion and inefficiencies during COVID-19 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEnvironmental factors such as unsuitable spaces, inadequate ventilation, and crowding at entry points increased transmission risks. These findings align with Morawska \u0026amp; Milton (2020) and Dietz et al. (2020), underscoring the importance of proper ventilation, safe environmental design, and passenger flow management to mitigate airborne spread (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Operational challenges included lack of dedicated screening and quarantine areas and poor ventilation. Infrastructure improvements incorporating well-ventilated isolation spaces and smart passenger flow technologies are vital.\u003c/p\u003e \u003cp\u003eBehavioral and cultural factors significantly influenced screening success. Passenger resistance to protocols, misinformation, and linguistic and cultural diversity impeded full cooperation. Literature by Betsch et al. (2020) and Van Bavel et al. (2020) confirms that targeted, participatory cultural interventions substantially increase public compliance (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Interviewees emphasized multilingual messaging, diverse media use, trust-building, and ensuring passenger rights and support during quarantine to reduce behavioral resistance. Multiple studies indicate that social inequalities, cultural diversity, and population attitudes profoundly influence the acceptance and implementation of border health measures. Resistance from travelers, misinformation, and privacy concerns are significant barriers that cannot be overcome without culturally sensitive and participatory approaches involving community engagement (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLegal ambiguities regarding data privacy, organizational responsibilities, and authorities posed significant challenges. Gostin et al. (2019) identify such legal gaps as major weaknesses in global health crisis management (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Lack of coherent legislation caused enforcement ambiguities and privacy concerns. Precise legal frameworks, staff legal training, and judicial cooperation are essential for effective regulation.\u003c/p\u003e \u003cp\u003eFragmented communication, inconsistent messaging, and limited use of modern information technologies reduced process effectiveness. This agrees with Lowe et al. (2022) and Nan et al. (2022), highlighting the role of timely, transparent, and multilingual communication in fostering public cooperation (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Successful countries use centralized digital communication platforms, which could serve as models. Participants stressed pre-travel information dissemination and feedback channels.\u003c/p\u003e \u003cp\u003eFinancial and economic constraints permeated all aspects of screening, hindering infrastructure development, expert recruitment, and advanced technology use. Experiences from Sweden and Canada show that sustainable funding and private sector involvement optimize resources and service quality (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Interviewees identified financial shortages as a critical barrier, underscoring the need for government support and economic facilitation for quarantined travelers.\u003c/p\u003e \u003cp\u003eThis study has several limitations. As a qualitative study using semi-structured interviews, recall and social desirability biases may have affected participants\u0026rsquo; responses and limited disclosure of sensitive information. Focusing only on air border crossings excludes land and sea ports, limiting generalizability. Cultural, economic, and infrastructural differences further restrict the applicability of results to other countries with different health systems or governance. Limited access to official documents and strict security measures limited contextual analysis and observation. The long time since the pandemic peak may have reduced the immediacy and accuracy of findings. Finally, despite purposive sampling, the small sample size may not capture all perspectives, affecting the comprehensiveness of issues and solutions.\u003c/p\u003e \u003cp\u003eFuture research should examine border health measures at land and sea crossings to complement findings from airports. Studies conducted closer to pandemic peaks are needed to better capture real-time challenges. Quantitative and comparative research across different cultural and economic contexts can improve generalizability. Additionally, evaluating the role of digital technologies and reviewing relevant regulations in border settings may enhance pandemic response effectiveness.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study examines challenges in COVID-19 screening and management at Iran\u0026rsquo;s air border crossings. Key issues include inadequate human resources, technological limitations, poor organizational coordination, legal gaps, and environmental factors, which hinder effective border health measures and compliance with International Health Regulations.\u003c/p\u003e \u003cp\u003eProposed solutions, such as integrated digital platforms, enhanced staff training, improved quarantine facilities, and clearer legal mandates, are based on participants\u0026rsquo; insights. Successful implementation will require ongoing multisectoral collaboration and resource allocation. Overall, the findings highlight the complexity of border health management during pandemics and the need for alignment with international frameworks to improve pandemic response.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePolymerase Chain Reaction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformation Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArtificial Intelligence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants voluntarily consented after being informed about study objectives and data usage. Confidentiality and anonymity were strictly maintained. This study was conducted in accordance with ethical standards, and ethical approval was obtained from the relevant committee (Code: 1402.135REC.PHNS.SBMU.IR).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Shahid Beheshti University of Medical Sciences under grant number 43013183. This study was conducted as part of a Ph.D. thesis at the School of Public Health and Safety, Shahid Beheshti University of Medical Sciences. The funding body had no role in study design, data collection, analysis, interpretation, or manuscript preparation. This study is obtained from a Ph.D. thesis at School of Public Health and Safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMK and HP conceptualized the study. The literature search was conducted by HP and MG. Data collection, including conducting interviews, was carried out by HP, AN, and AK. Data analysis and initial drafting of the manuscript were performed by HP, AN, MG and AK. MK provided critical revisions to the manuscript. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to all individuals and organizations that contributed to the completion of this study. We especially thank the participants who generously shared their time, expertise, and insights. We also appreciate the support of the staff at the border health base during the field visit, whose cooperation was invaluable. Finally, we acknowledge the guidance and feedback from our academic mentors and colleagues throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhD Candidate at Shahid Beheshti University of Medical Sciences, Tehran. His research focuses on infectious diseases, with interests in their management, control, and informing health policy to improve public health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMG\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePublic Health expert at Shahid Beheshti University of Medical Sciences, specializing in health education and promotion. Committed to advancing public health management and supporting health policymakers in addressing community health challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMD-MPH working in the Deputy of Health at Tehran University of Medical Sciences. Responsible for controlling and managing communicable diseases, focusing on public health management and policy implementation for infectious disease control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAK\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBiostatistician at Shahid Beheshti University of Medical Sciences collaborating with epidemiologists. Research interests include health determinants and providing statistical support to health policymakers and decision-makers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMK\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProfessor of Epidemiology at Shahid Beheshti University of Medical Sciences and affiliated with the Ministry of Health, Iran. His work centers on infectious disease control, management, and promoting effective health policies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKesheh MM, Hosseini P, Soltani S, Zandi M. An overview on the seven pathogenic human coronaviruses. 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Can Tax J. 2020;68:863.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Border Health, Infectious Diseases, Pandemic Preparedness, Management, Airport","lastPublishedDoi":"10.21203/rs.3.rs-7674653/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7674653/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInternational air border crossings are crucial for controlling the spread of respiratory pandemics like COVID-19. Effective screening at these points is vital for national health security and meeting global health obligations under the revised International Health Regulations (IHR 2005). This qualitative study aimed to identify and analyze the challenges, barriers, and proposed solutions in COVID-19 screening and management at Iran\u0026rsquo;s air border crossings and situates these findings within the context of global health governance and pandemic response frameworks.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing purposive sampling, twelve key stakeholders involved in border health management were interviewed between Mar and Nov 2024. Data were collected through semi-structured interviews and supplemented by a field visit to Imam Khomeini International Airport\u0026rsquo;s border health bas and a review of relevant international regulations and recent scholarly literature. Content analysis combined with Fishbone root cause analysis was employed to explore underlying factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFindings revealed multifaceted challenges including inconsistent implementation of screening protocols, shortage of trained personnel, inadequate technological infrastructure, poor interagency coordination, and legal ambiguities related to data privacy and quarantine enforcement. Behavioral factors such as passenger resistance and limited airline cooperation further undermined screening effectiveness. Additionally, the assessment identified significant gaps in meeting global standards and International Health Regulations core capacities (points of entry, public health emergency preparedness and surveillance) at air border points. Proposed solutions emphasized integrated digital platforms for real-time data sharing, enhanced staff training, improved quarantine facilities, legal reforms, and targeted multilingual communication campaigns.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study indicates that strengthening air border screening during pandemics requires a multisectoral approach aligned with international health regulations. Identified human, technical, organizational, legal, and environmental challenges may hinder full compliance with these regulations. Addressing these barriers through practical solutions could improve preparedness and response to health emergencies at both national and international levels.\u003c/p\u003e","manuscriptTitle":"Challenges and Barriers to Effective COVID-19 Screening at Iran’s Air Border Crossings: A Qualitative Study and Proposed Solutions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 12:25:37","doi":"10.21203/rs.3.rs-7674653/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-23T05:13:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T21:30:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T04:49:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217273824764767559285530672548160892448","date":"2026-01-19T02:02:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242286926371814273966770547218355523582","date":"2026-01-11T00:02:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T13:01:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-01T10:18:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-03T09:34:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Globalization and Health","date":"2025-11-01T20:56:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3da9915-823f-419c-afcf-89e8ed2f0f1b","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:11:23+00:00","versionOfRecord":{"articleIdentity":"rs-7674653","link":"https://doi.org/10.1186/s12992-026-01208-w","journal":{"identity":"globalization-and-health","isVorOnly":false,"title":"Globalization and Health"},"publishedOn":"2026-04-13 15:57:56","publishedOnDateReadable":"April 13th, 2026"},"versionCreatedAt":"2026-01-12 12:25:37","video":"","vorDoi":"10.1186/s12992-026-01208-w","vorDoiUrl":"https://doi.org/10.1186/s12992-026-01208-w","workflowStages":[]},"version":"v1","identity":"rs-7674653","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7674653","identity":"rs-7674653","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}