Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Pregnant Women’s Knowledge, Attitude and Self-Protective Measures Practice regarding Corona virus prevention: Health Educational Intervention

Aziza Ibrahim Mohamed1, Doaa Mohamed Sobhy Elsayed2, Taisser Hamido Abosree,2 Nadia Abd ElHamed Eltohamy 4 1Obstetrics and Woman Health Nursing, Faculty of Nursing, Benha University 2 , community Health Nursing, Faculty of Nursing, Benha University ,4Maternal and Newborn Health Nursing Faculty of Nursing, Helwan University.

Abstract

Background; Boosting pregnant women knowledge attitude and practice regarding COVID19 are key elements that ensure pregnant women health and safety. Pregnant women’s adherence to control measures is affected by their knowledge, attitudes, and practices (KAP) towards COVID-19. Aim: this study aimed to evaluate the effect of health educational intervention on pregnant women knowledge, attitude and self-protective measures practice toward prevention of COVID 19. Setting: the current study was conducted at six maternal and child health centers affiliated at Kalioubia governorate. Research Design: a quasi-experimental design was used. Sample: simple random sample included 340 pregnant women, recruited as (160) in control group and (180) study group. Tools: three tools were utilized for data collection; A structured interviewing questionnaire, knowledge assessment sheet, COVID 19 related attitude assessment tool, and COVID 19 preventive measures practice assessment. Results: the present study revealed a highly statistical significant improvement of knowledge attitude and practice between subjects at both study and control group. In addition study group subjects indicated high satisfaction level regarding the study guideline. Conclusion: heath educational guideline is effectively improving pregnant women knowledge, attitude and self-protective measures practice regarding prevention of COVID 19. Keywords: Heath education, Guideline, knowledge, attitude, practice &COVID19.

Corresponding Author: Aziza Ibrahim Mohamed Hassan, [email protected]

Introduction March 11, 2020, the WHO declared COVID-19 a pandemic (WHO, disease 2019 2020).COVID 19 is highly infectious (COVID-19 is an emerging respiratory disease and its main clinical symptoms disease that is caused by a novel vary from fever, dry cough, fatigue, coronavirus, which was first diagnosed in myalgia, and dyspnea to acute respiratory December 2019 in Wuhan, China, and distress syndrome, difficult-to-tackle subsequently spread to many other metabolic acidosis, septic shock, and countries. Numerous countries have bleeding and coagulation reported increasing numbers of confirmed dysfunction (The Novel Coronavirus cases and deaths per day; therefore, on Emergency Response

260 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Epidemiology Team, 2020) & (Chen et women needs, so the aim of the current al., 2020). Pregnant women might be at study is to evaluate the effect of increased risk for severe illness from educational intervention on pregnant COVID-19 compared to non-pregnant women knowledge, attitude and practice people. Additionally, there may be an toward COVID19 prevention. increased risk of adverse pregnancy outcomes, such as preterm birth, among Significance of the study pregnant people with COVID-19 (CDC, 2020). The anatomical and physiological Pregnancy is a time full of changes occurring during pregnancy excitement and anticipation. But for make the pregnant women more expectant women encountering the vulnerable to severe infections as an outbreak of the coronavirus disease increase in the transverse diameter of the (COVID-19), fear, anxiety and thoracic cage and an elevated level of the uncertainty are clouding this otherwise diaphragm, decrease maternal tolerance to happy time. The battle against COVID-19 hypoxia. Lung volume changes and is still continuing all over the world. To vasodilation can lead to mucosal edema guarantee the final success, people’s and increased secretions in the upper adherence to these control measures are respiratory tract. In addition, alterations in essential, which is largely affected by cell-mediated immunity contribute to the their knowledge, attitudes, and practices increased susceptibility of pregnant (KAP) towards COVID-19 in accordance women to be infected by intracellular with KAP theory (9,10). Moreover different organisms such as viruses (Schwartz & . study added that from the Lessons learned Graham, 2020) After initial studies from the SARS outbreak in 2003 that suggested that pregnant mothers were not knowledge and attitudes towards at a higher risk of complications of infectious diseases are associated with COVID-19 infection, recently Sweden level of panic emotion among the and the US investigations have indicated population especially pregnant women that both pregnant and postpartum and risk group, which can further mothers are at increased risk of severe complicate attempts to prevent the spread complications associated with COVID-19 of the disease (11,12)]. To facilitate (Collin ,2020) &(Ellington,2020) . In an outbreak management of COVID-19 analysis of 8207 cases of COVID-19 in among pregnant women there is an urgent the obstetric population, the Centers for need to understand pregnant women’s Disease Control and Prevention (CDC) awareness of COVID-19 at this critical reported a higher risk of ICU admission moment. Various research studies clearly and compared to indicate the importance of improving no pregnant women, although no higher residents’ COVID-19 knowledge via risk of mortality was identified (CDC, health education, which may also result in 2020). Health education programs play an improvements in their attitudes and important role in improving COVID-19 practices towards COVID-19 (13, 14). These knowledge and also are helpful for findings further suggest that the health encouraging an optimistic attitudes and education intervention would be more maintaining safe practices (Zhong et al., effective if it targets certain demographic 2020). groups, for example, the COVID-19 knowledge may be greatly increased if During antenatal visits nurse is the the health education programs are primary health care provider that provide specifically designed for pregnant women. health education regarding pregnant

261 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Aim of the research Study was conducted at 6 different maternal and child health centers were The aim of the current study was randomly selected at Benha city where to evaluate the effect educational pregnant women go to have their intervention guideline on knowledge, antenatal care including (immunization, attitude and self –protective measures follow up),and where heath related practice of pregnant women regarding educational intervention were given. COVID 19 prevention. Subjects Research Objectives: Type: The research sample was 1. Assess pregnant women randomly selected using simple random knowledge, attitude and self-protective sample technique as, 3 or 4 women were measures practice regarding COVID 19 randomly selected daily from total prevention before implementation of women admitted to the study setting all educational intervention. the pregnant women.

2. Validate the designed Size: a total 340 pregnant women educational intervention guideline for (160) were included in the control group pregnant women regarding COVID 19 and (180) in the study group. prevention. Recruitment strategy: 3. Evaluate effect of educational intervention guideline on pregnant Pregnant women were directly women knowledge, attitude and self- asked to participate in the study after protective measures practice toward explanation of the purpose of the study. COVID 19 prevention. For the control group subjects were recruited from three MCH centers for a Research Hypothesis: period of first month, and the study group subjects were recruited from other three Educational intervention guideline MCH centers. exhibit improvement in knowledge, attitude and self-protective measures Tools of data collection practice regarding COVID 19 prevention. three tools were used for collecting data:

Subjects and Methods First tool: Research design An interviewing questionnaire; it A quantitative quasi -experimental was divided into two Parts 1) personal nonequivalent groups design was utilized data, and obstetrical history such as in the current study in order to decrease (gravida parity and gestational age);2) time of contact with pregnant women to knowledge related (COVID-19). This avoid risk for transmission of COVID 19 questionnaire area was developed infection. following review of literatures on the (WHO,2020) & (CDC ,2020).It was Setting consisted of six closed ended questions , for each question a number of correct answer was given for: definition of COVID -19 (2 ) correct answers, for

262 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 signs and symptoms of COVID -19 (9) Uncertain attitude ….60-75 of correct answers, for mode of total practice score (17-20 score). transmission & factors increase risk for COVID -19 (5) correct answers, for risk Positive attitude ……> 75% of group for COVID -19 (10) correct total practice score (>20 score). answers and finally for Protective measures against COVID-19 question (8) Third tool: correct answers . The study subject was asked if it is correct or incorrect).The A practice questionnaire study subjects answers were scored as (1) concerning self-protective measures score for correct answer & (0) score of regarding prevention of COVID -19, it incorrect answers. The total knowledge was developed following review of correct answers number was (34). literatures on the World Health Organization recommendations on the The total knowledge score was measures to prevent human-to-human calculated as the following: transmission of COVID-19 infection (WHO, 2020). This questionnaire had (7 Poor knowledge <60% of total main practice topics to reduce COVID - knowledge score (20 score). 19 infection among pregnant women). Each of these 7 had a practiceitems.1) the Fair knowledge 60-75 of total hand washing topics included (5 items) knowledge score (21-25 score). concerning with technique of hand washing, times for hand washing, Good knowledge > 75% of total frequency of hand washing 2) The mask knowledge score (>25 score). wearing topics included (5 items) concerning with techniques of wearing, Second tool: removing and getting rid of the mask, in addition times of wearing the mask and A three point Likert scale contains frequency for wearing the mask per day. (9) items was designed by the researchers 3)The environmental cleaning topic after reviewing related literatures (Zhang, included (4 items) concerning with keep et al.,2020) ,( Chen etal.,2020) to home environment clean and well evaluate the study subjects attitude ventilated, clean home surface with toward COVID -19 infection antiseptic solution, keep home &prevention .This Likert scale 9 items environment calm and reduce stressful were verified to assess attitude toward situations. 4)The social distance topic COVID -19 infection, prevention and contained (4 items) concerning world their attitude if they had a COVID-19 health organization recommendations infection. The current study Likert scale including keep a distance of 3meter at was scored as the following (1) for least, avoid crowded places, isolation in disagree, (2) for uncertain, and (3) case of having minor symptoms as agree .The total attitude score was (27). cough ,sneeze or headache , maintain away from persons who has a minor The total attitude score was symptoms as cough ,sneeze or headache. calculated as the following: 5) The nutrition for pregnant woman contained (4 items) including increase Negative attitude ……<60% of intake of food rich in protein, iron and total attitude score (16 score). calcium intake , increase intake of vitamins and fluids ,decrease intake of fat

263 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 and salty foods, decrease intake of to test the content validity. The result of chocolate and confine .6) Rest and sleep content validity index (CVI) delineated topic included (3 items) Develop a strongly accepting tools, it measured relaxing bedtime routine, Keep a (0.89). In addition, the content of regular bed and wake time, and Limit educational guideline was reviewed by breathing problems by elevating your the panel of expertise and the guideline head when you sleep.7) Adherence of contents were reviewed critically and intake of supplementation and follow up validated its contents. topic contained (3 items ) concerning take iron , calcium and vitamins Reliability supplementation as prescribed by the physician, attendance at times of The reliability was done by antenatal visits, and don’t hesitate to seek Cronbach's Alpha test which revealed that medical attention in case of having minor each of the three tools consisted of signs as cough, sneeze and fever. For relatively homogenous items as indicated each practice item; the study subjects by the moderate to high reliability of each were asked to select if they do the tool, it was (0.93) for knowledge tool, practice rarely (done 1or 2 times per day), (0.94) for self-protective measures, (0.945) sometimes (done 2or 3 times per day) or and (0.87) attitude tool . usually ((done more than 3 times per day).the practice questionnaire scored as Ethical Considerations the following (1) for rarely done, (2) for sometimes done, and (3) for usually done. An official permission was granted from directors of 6 Maternal and The total self-protective measures Child Health care centers, to facilitate practice score was (93). data collection process. Written informed consents were obtained from women The total self-protective measures before data collection and after explaining score was calculated as the following: the purpose of the research. Anonymity was assured as the filled questionnaires Unsatisfactory self-protective were given a code number. The measures practice ……………<60% of researchers informed women that the total practice score (55 score) information obtained will be confidential. The research maneuvers do not entail any Satisfactory self-protective risk effects on women. The women were measures practice …………….60-75 of informed about having the right to total practice score (56-69 score) withdraw at any time without giving any reason. Highly satisfactory self-protective measures practice ………….> 75% of A Pilot Study: total practice score (>69 score). The pilot study was carried out on Content validity 20 women, which was taken in 10 % of the estimated total duration to collect the The tools of data collection were data (3 days). It is mainly established to submitted to a panel of 3 nursing experts test the simplicity, clarity and in the field of Obstetrics and Gynecology applicability, ascertain the relevance and & 4 medical expertises in the field of content validity of the tools, as well as community health and pandemic disease estimation of the time needed to fill the 264 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 tools .According to the results of the pilot A total (3-4) women were interviewed study, the tools were clear and applicable, daily. The data obtained during this phase relevant and valid; however, few words were constituted the base line for further were modified and no problem interfered comparison to evaluate the effect of the with the process of data collection. The educational guideline. estimated time needed to fill the data collection tools was 15 minutes. C- Planning phase: Based on Following this pilot study the tools were results obtained from control group made ready for use. Women involved in during assessment phase, the educational the pilot excluded from the study to avoid guideline was developed by the contamination of the sample. researchers in a form of printed Arabic procedure: booklet to improve the studied women’s deficit knowledge, attitude and practice Data of the current study was regarding COVID -19. Different methods collected during a period of 5 months of teaching, and instructional media like from the beginning January 2020 and video & demonstration were utilized to completed at the end of May, 2020. The explain guideline to studied women. researcher visited the previously mentioned setting 5 days/week, from 9.00 Objectives of educational am to 12.00 pm. To fulfill the aim of this guideline were constructed and included research, the following phases were the following: adopted, preparatory phase, interviewing and assessment phase, planning phase, General Objectives aimed to equip implementation of the educational the studied women with the essential intervention phase and evaluation phase. required knowledge and self- practice concerning COVID -19 preventive A-Preparatory phase: The measures. researchers conducted this phase through reviewing international related literature Specific Objectives aimed to concerning the various aspects of the familiarize the studied women with research problem. This phase helped the abundant knowledge and self-care researchers to be familiar with the protective measures practice concerning seriousness of the problem, and the COVID -19 of; its definition, signs and researchers be directed by sample symptoms, characteristics, risk factors, information help them to preventive measures, etc…. adequately the required data collection tools. D- Implementation of the educational intervention phase. B-Interviewing and assessment phase: In this phase the researcher The designed educational interviewed the women in the control guideline was provided for the women group to collect baseline data (pre-test). through 2 different sessions.1) one At the beginning of the interview, the theoretical session was done for a period researchers welcomed the participating of 30 minutes, and the researchers gave women, explained the purpose of the attention that each woman follow research and familiarized them with all precaution measures to avoid COVID 19 information about the research (purpose, infection as (wearing gloves & mask and duration, and activities) and obtained maintain social distance.2) one practical their written to participate in the research. session was done for a period of 15

265 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 minutes, the researches educate women which mean that the two groups under techniques of hand washing, wearing face study are homogenous. mask, removing and how to get rid of the mask. Total educational intervention time Table (2): Illustrates that there was reached 140 hours / 9 weeks, with (20 no statistically difference was detected hours /week-4 hours /daily) for all women between both groups related to obstetric recruited in study group. Women were history, which means that the two groups gathered in the waiting room of MCH under study are homogenous. centers. Women in the study group received the educational intervention, the Table (3): Reveals that there was a educational intervention was provided highly statistically significant difference through two scheduled sessions. These was observed in knowledge between two sessions were repeated to each studied groups post guidelines at p-values < 0.001. women. Each session took about 15-20 minutes. At the end of each session, Table (4): Indicates statistical and women' questions were discussed to a highly statistical significant difference correct any misunderstanding. found in knowledge between two groups post guidelines at p-values < 0.05. < E- Evaluation phase: this phase 0.001. was evaluated one month after implementation among the study group Table (5): Denotes that, a highly subjects using the same format of tools statistical significant difference was found that used to evaluate knowledge, practice in knowledge regarding risk group for and attitude, each was phoned to assure COVID 19 between two groups post attendance to next antenatal visit that is guidelines. after one month form educational intervention. Table (6): Shows that there was a highly statistical significant difference III- Statistical Design: Data found in knowledge between the two analysis was performed using IBM SPSS groups post guidelines at p-values < 0.001. statistical software version 22. The data were explored. Descriptive statistics was Table (8): Reveals that there was a used for continuous variables [mean and highly statistical significant difference standard deviation (SD)] and frequency was found in attitude between the two for categorical variables. Qualitative groups post educational guidelines at p- variables were compared using qui square values < 0.001. test (X2) as the test of significance. Correlation coefficient (r) Pearson was Table (7): Shows that there was a used to evaluate association between highly statistical significant difference studied variables. A significant level found in practices of self protective value was considered when p-value ≤ measures between the two groups post 0.05. educational guidelines at p-values < 0.001.

Results: Table (9): denotes that76.7% of the study group disagreed that guidelines Table (1): Shows no statistically prepared with easily language and 83.3% difference was detected between both of them agreed that guidelines prepared in groups related to personal characteristics, the way that help you to improve your practices.

266 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Discussion group had a good level of knowledge as compared with more than two third of Pregnant women are particularly control group’s subjects that had a poor vulnerable to infectious diseases that can level of knowledge. This might be due to cause both maternal and fetal adverse the educational guidelines succeeding in outcomes, compared to the non-pregnant increasing the study group knowledge. counterparts. During pregnancy, women These finding agreed with Zhang etal. experience a series of immunological (2020) who added that heath education transformations that allow the immune regarding infectious disease prevention is system to tolerate and support the highly effective. growing fetus while still maintaining antimicrobial defense and tissue repair. Concerning the studied subjects (Bouaziz et al., 2020). knowledge regarding COVID 19 definition, the present study revealed that, Regarding personnel more than two fifth of the control group characteristics of studied subjects, more and the majority of the study group had than half of study subjects aged 25 to <30 correct answer regarding COVID 19 is years with a mean age of 27.84±3.75 & viral infection and affect respiratory 26.97±2.76 years, also more than half of system respectively and fever & dyspnea studied subjects had secondary education, as signs and symptoms of COVID 19. while more than two thirds of them were These results were agreed with Bekele lived in rural area and weren't work. etal. (2020) who indicated that the vast These findings were in the same line with majority of study sample knowing that Nwafor et al.(2020), who studied COVID 19 is a viral and infectious dieses “Knowledge and practice of preventive and knowing different COVID 19 signs & measures against COVID-19 infection symptoms. among pregnant women in a low-resource African setting”, as the mean age of the Concerning risk group for study subjects was 24.6 ± 6.3 years, COVID- 19, the present study revealed ranged from 18 to 42 years, more than that more than two thirds of control group one third had secondary education and had incorrect answer regarding patient more than half reside in urban area.in with heart disease, chronic kidney addition nearly half of studied subjects diseases, chronic lung diseases and were primigravida, and at gestational age obesity. This might be due to inadequate of 20-<30 weeks .on the other hand knowledge they had and lack of Yassa, et al (2020), studied the Near- educational program before. While on the term pregnant women’s attitude toward, other hand the majority of the study group concern about and knowledge of the had correct answer regarding liver disease COVID-19 pandemic in Turkey, added and severe obesity are more risk group that median gestational week of the for COVID- 19.These findings matched women were 35 ± 11 weeks by Miller, (2020) , who stated that more risk factors for a more severe course of As regarding the effect of COVID-19 currently include people who educational intervention on pregnant are or have liver disease and body mass women knowledge regarding COVID 19; index of 40 or greater. highly statistical significance difference was indicated between both study and Concerning the study groups` control group (p<0.001). The majority of knowledge regarding protective measures studied subject included in the study against COVID 19, more than two thirds 267 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 had correct answer regarding regularly infection is associated with a rise in the and thoroughly clean hands with an body temperature bike in the first period alcohol-based hand rub or wash them of pregnancy, it may be associated with with soap and water, maintain at least 1 some birth defects of the fetus. According meter (3 feet) distance between yourself to Karimi-Zarchi et al.(2020) , who and others, avoid going to crowded places, conducted study on `vertical transmission avoid touching eyes, nose and mouth, and of Coronavirus Disease 19 (COVID-19) wear a mask to avoid infecting others. from infected pregnant mothers to These findings agreed with Nwafor et al. neonates, who found that currently there (2020) , who found that study participants was no evidence for intrauterine vertical had the following level of knowledge transmission of COVID-19 from infected regarding COVID 19 preventive pregnant mothers to their fetuses. measures ;washing hands frequently with However, infected mothers may be at soap and water or rubbing hands with increased risk for more severe respiratory alcohol-based sanitizers (93.7%), complications. It is well known that an maintaining at least 1 meter distance infected mother can transmit the COVID- between yourself and others (87.7%), 19 virus through respiratory droplets avoiding touching eyes, nose and mouth during breastfeeding. While these with hands (75%), covering mouth and findings disagreed with Yassa, et al nose when coughing or sneezing (97.5%), (2020), who reported that half of the wearing facemask in public (98.6%) and women were reported that they either had staying indoor (74.3%). no idea about or think the breastfeeding is not safe during the outbreak. Greater part Concerning the effect of of the participants does not know if educational intervention on pregnant COVID-19 cause birth defects (76%) or women attitude toward COVID 19titude preterm birth (64.5%). toward, there was a highly statistical significant difference was found in As regarding the effect of attitude between the two groups post educational intervention on pregnant educational guidelines. This might be due women self-protective measures practice to educational guidelines was effective in for prevention of COVID- 19, there was changing pregnant women` attitude highly statistical significance difference because improve knowledge and practice between both study and control group is highly associated with change attitude (p<0.001). This might be due to that positively. educational guideline help to improve pregnant women skills including wearing The highly positive attitude toward mask ,and recognizing the importance of COVID 19 was concerning that there is self-protection ,and recognizing that no evidence that COVID-19 may cause COVID 19 may be avoided by congenital anomalies for fetus and demonstrating protective measures as women with COVID-19 can breastfeed educated during educational intervention. her baby, by following precaution during These findings supported by Miller. breast feeding. This might be due to the (2020) & Madappuram& Kamel (2020) limited information available indicates who recommended that improving that there is no evidence of the virus residents’ COVID-19 knowledge via spreading through breast milk, as studies health education, which may also result in of SARS have indicated that the virus improvements in their attitudes and does not exist in breast milk and this virus practices towards COVID-19. is compared to other viruses and the

268 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Regarding hand washing, & mask practiced frequent hand washing with wearing more than three quarters of the soap and water while 20.4% practiced study group had highly satisfactory of at least 1 meter practices, in addition less than three between them and others, and 32.7% of quarters of them had highly satisfactory the participants used facemask in public. reported practices regarding social distance. These findings agreed with As regarding study group subjects Madappuram & Kamel (2020) (20), who evaluation of prepared educational stated that the greatest tool to prevent guideline, the majority of them added that COVID- 19 infection in pregnant women guideline answer all of their questions is social distancing and maintaining and were useful in prevention .these hygiene. However these findings findings may be due to that guideline was disagreed with Nwafor et al. (2020), who prepared with simple Arabic language found that only 26.8% participants and had a proper pictures for clarification.

269 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Table (1): Distribution of personnel characteristics of the studied subjects (n=340)

Control group Study group Chi P value Variables N=160 N=180 square No % No % test Age in years 1.51 >0.05 20- 38 23.7% 35 19.4% 25- 82 51.3% 100 55.6% 30- 38 23.7% 41 22.8% 35-40 2 1.3% 4 2.2% Mean ±SD 27.84±3.75 26.97±2.76 Educational qualification 5.26 >0.05 Read and write 23 14.4% 34 18.9% Secondary education 100 62.4% 102 56.7% University 34 21.3% 44 24.3% Postgraduate 3 1.9% 0 0.0% Residence 0.899 >0.05 Urban 52 32.5% 50 27.8% Rural 108 67.5% 130 72.2% Occupational status 0.950 >0.05 Yes 55 34.4% 53 29.4% No 105 65.6% 127 70.6%

Table (2) : Distribution of obstetric history of the studied subjects(n=340 )

Control group Study group Chi P value Variables N=160 N=180 square No % No % test Gravida Primigravida 81 50.6% 89 49.4% 0.959 >0.05 2-3 44 27.5% 44 24.4% >3 35 21.9% 47 26.2% Times of labor Nulliparous 81 50.6% 89 49.4% 0.941 >0.05 2-3 52 32.5% 66 36.7% >3 27 16.9% 25 13.9% Gestational age 20-<30 93 58.1% 90 50.0% 2.25 >0.05 30-40 67 41.9% 90 50.0% Mean ±SD Regular attendance of antenatal care visits 0.112 >0.05 Yes 90 56.3% 98 54.4% No 70 43.7% 82 45.6%

270 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Table (3): Distribution of studied subjects knowledge regarding definition, signs and symptoms of COVID 19 (n=340 )

Signs and Control group Study group Chi P value symptoms of N=160 N=180 square COVID 19 Incorrect Correct Incorrect Correct test No % No % No % No % Definition of COVID 19 Viral infection 82 51.2 78 48.8 36 20.0 144 80.0 36.50 <0.001** Affect 52.10 <0.001** respiratory 79 49.4 81 50.6 24 13.3 156 86.7 system Signs and symptoms of COVID 19 Fever 82 51.2 78 48.8 23 12.8 157 87.2 58.73 <0.001** General fatigue 64 40.0 96 60.0 30 16.7 150 83.3 23.05 <0.001** Sore throat 81 50.6 79 49.4 56 31.1 124 68.9 13.40 <0.001** Lost sense of 13.61 <0.001** 86 53.8 74 46.2 61 33.9 119 66.1 smell Lost sense of 16.58 <0.001** 61 38.1 99 61.9 33 18.3 147 81.7 taste Diarrhea 90 56.2 70 43.8 60 33.3 120 66.7 18.04 <0.001** Vomiting 80 50.0 80 50.0 22 12.2 158 87.8 57.56 <0.001** Headache 50 31.2 110 68.8 16 8.9 164 91.1 27.07 <0.001** Dyspnea 77 48.1 83 51.9 54 30.0 126 70.0 11.74 <0.001** Table (4): Distribution of studied subjects knowledge regarding mode of transmission & risk factors of COVID 19 (n = 340 )

Mode of Control group Study group Chi P value transmission N=160 N=180 square & risk factors Incorrect Correct Incorrect Correct test No % No % No % No % Direct transmission flying spit 3.27 <0.05* from patient 62 38.8 98 61.2 53 29.4 127 70.6 while coughing or sneezing Indirect transmission Touching 11.03 <0.001** contaminated surfaces and tools, and then 78 48.8 82 51.2 56 31.1 124 68.9 touching the mouth, nose, or eye. Factors increase risk for COVID 19 infection Sharing food 27.17 <0.001** and drink 86 53.8 74 46.2 47 26.1 133 73.9 utensils Eat foods 34.35 <0.001** without cooking, 77 48.1 83 51.9 33 18.3 147 81.7 especially meat and eggs crowded places 9.61 <0.05* like the train 57 35.6 103 64.4 37 20.6 143 79.4 and transportation

271 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Table (5): Distribution of studied subjects knowledge regarding risk group for COVID 19 (n=340).

Control group Study group Chi P value Risk group N=160 N=180 square for COVID Incorrect Correct Incorrect Correct test 19 No % No % No % No % Diabetic 15.92 <0.001** 72 45.0 44 24.4 88 55.0 136 75.6 patient Patient with 106.41 <0.001** 127 79.4 42 23.3 33 20.6 138 76.7 heart disease Chronic 59.23 <0.001** kidney disease being 114 71.3 53 29.4 46 28.8 127 70.6 treated with dialysis Chronic lung 37.02 <0.001** 108 67.5 62 34.4 52 32.5 118 65.6 disease Hemoglobin 40.31 <0.001** 87 54.4 38 21.1 73 45.6 142 78.9 Disorders Immune- 13.28 <0.001** 75 46.9 50 27.8 85 53.1 130 72.2 compromised Pregnant 22.82 <0.001** 89 55.6 54 30.0 71 44.4 126 70.0 mothers Liver disease 82 51.2 27 15.0 78 48.8 153 85.0 51.10 <0.001** People aged 16.78 <0.001** 65 years and 76 47.5 47 26.1 84 52.5 133 73.9 older Severe 103.13 <0.001** 118 73.8 34 18.9 42 26.2 146 81.1 obesity

272 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Table (6) : Distribution of studied subjects knowledge regarding Protective measures against COVID 19 (n=340 )

Control group Study group Chi P value Protective N=160 N=180 square measures Incorrect Correct Incorrect Correct test against No % No % No % No % COVID19 Regularly and thoroughly clean hands with an alcohol-based 119 74.4 41 25.6 50 27.8 130 72.2 73.57 <0.001** hand rub or wash them with soap and water. Maintain at least 1 meter (3 feet) distance 47.17 <0.001** 99 61.9 61 38.1 45 25.0 135 75.0 between yourself and others. Avoid going to crowded 112 70.0 48 30.0 53 29.4 127 70.6 55.77 <0.001** places. Avoid touching eyes, 58.50 <0.001** 118 73.8 42 26.2 58 32.2 122 67.8 nose and mouth. Covering mouth and nose with bent elbow or tissue when cough or 56.18 <0.001** 125 78.1 35 21.9 68 37.8 112 62.2 sneeze. Then dispose of the used tissue immediately and wash hands. If have minor symptoms such as cough, headache, mild fever Stay home and self-isolate even with 121 75.6 39 24.4 43 23.9 137 76.1 90.80 <0.001** minor symptoms Wear a mask to avoid 55.63 <0.001** 111 69.4 49 30.6 52 28.9 128 71.1 infecting others Seek medical 63.73 <0.001** 120 75.0 40 25.0 57 31.7 123 68.3 attention

273 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Figure (1): percentage distribution of total knowledge score of the studied subjects regarding COVID 19 infection. e r Table (7): Distribution of studied subjects attitude regarding COVID 19 (n=340). e a u u l P i q Control group N=160 Study group N=180 a h s v Disagree Uncertai Agree Disagree Uncertai Agree C Attitude

n n * 6 1 9 % % % % % 0 . 0 9 5 6 1 9

No % No % No % No % 5 ...... % 0 4 1 7 0 1 3 0 3 . < 1 4 4 1 2 7 3 5

COVID-19 can easily 7 6 7 8 1 6 7 1 3 9 prevented * . % * 1 9 0 3 7 0 . . . . . 7 0 8 * . . 3 1 5 8 6 3 1 0 3 5 9 7 4 3 3 4 4 1 1 7 1 0 < 1 6 6 2 3 2

COVID-19 will finally be % % % % % 9 * *

successfully controlled 1 4 0 5 % % % % % . 0 . 3 0 8 7 5 2 . . . . . % 0 6 6 0 3 6 0 8 5 < . 1

I am worry to be affected 4 4 1 1 8 4 2 4 4 2 0 1 7 6 2 3 with COVID-19 5 * * 1 0 0 0 1 % % % % % . . 4 2 4 7 2 0

There is no evidence that 4 % . . . . . < 0 1 4 1 4 6 7 1 . 1 3 5 1 2 6 COVID-19 transmitted to 2 6 5 2 3 1 8 1 fetus from mother 5 8 2 1 4 * * 1 0 4 0 9 % % % % % . . 5 1 4 0 8 0

There is no evidence that 5 % . . . . . < 1 2 3 4 5 2 2 3 . 1 4 4 1 3 6 COVID-19 may cause 1 2 8 9 3 3 1 6 6 2 6 congenital anomalies for 4 fetus * * 1

Women with COVID-19 0 0 % % % % % . 3 4 0 6 9 8 0 4 . . . . . %

can breastfeed her baby, . < 4 0 5 3 2 3 6 . 4 4 1 4 5 9 3 by following precaution 1 4 5 9 5 7 6 2 7 9 during breast feeding 6

274 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4 * * 1 0 0 % % % % % . 3 9 1 0 6 4 0

Frequent hand washing 4 . . . . . % . < 1 3 5 0 4 0 6 5 . 3 5 1 3 6 reduce COVID-19 1 9 5 1 5 4 5 1 5 8 2 5

infection 9

Figure (2): percentage distribution of total attitude of the studied subjects regarding COVID 19 infection. Table (8): Distribution of studied subjects self-protective measures for prevention of COVID 19 (n=340 ) Practice Control group Study group Chi P N=160 N=180 squ value Unsatisfac Satisfacto Highly Unsatisfac Satisfacto Highly are tory done ry done satisfactor tory done ry done satisfactor test (<50%) 50-75% y done (<50%) 50-75% y done >75% >75% N % N % No % N % o o o . 2. 1 174. <0.00 Hand 7 49. 6 41. 1 8.7 3 20. 76. 5 8 3 42 1** Washing 9 4% 7 9% 4 % 7 6% 6% (5 items) % 8 . 3. 1 164. <0.00 Mask 7 48. 6 40. 1 11. 3 17. 78. 7 9 4 10 1** Wearing( 7 1% 5 6% 8 3% 2 8% 3% 6 items) % 1 Environ 194. <0.00 1. 1 mental 8 51. 6 38. 1 10. 2 15. 83. 85 1** 3 7 5 Cleaning 2 3% 2 7% 6 0% 7 0% 3% % 0 (6 items) . 4. 1 145. <0.00 Social 6 39. 8 50. 1 10. 3 21. 73. 8 4 3 76 1** Distance 3 4% 0 0% 7 6% 9 7% 9% (4 items) % 3 . Nutrition 150. <0.00 1. 1 49 1** for 8 50. 6 40. 1 9.4 6 35. 63. 2 1 1 Pregnant 0 0% 5 6% 5 % 3 0% 9% Woman % 5 (6 items) . Rest and 8 51. 6 38. 1 9.3 3 1. 7 40. 1 58. 141. <0.00

275 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

sleep (6 3 9% 2 8% 5 % 7 2 0% 0 3% 98 1** items) % 5 . 140. <0.00 2. 1 83 1** Supplem 5 36. 8 53. 1 9.3 5 27. 69. 5 8 2 entation 9 9% 6 8% 5 % 0 8% 4% and % 5 follow up

Figure (3): percentage distribution of self-protective measures score of the studied subjects regarding COVID 19 infection.

Table (9) : Distribution of study group subjects opinion regarding COVID 19 prevention guideline (n=180 ). Study group opinion regarding guideline Disagree Uncertain Agree No % Guideline answer all of your questions 3 1.7 39 21.6 138 76.7 Guideline help in reducing your anxiety 5 2.8 34 18.9 141 78.3 and stress Guidelines prepared in the way that help 3 1.7 27 15.0 150 83.3 you to improve your practices Guidelines prepared with easily language 6 3.3 41 22.8 133 73.9 Guidelines are useful for prevention of 2 1.1 63 35.0 115 63.9 COVID 19 Conclusion: Based on the findings of this study the following should be recommended: 1. Heath educational intervention The findings of the current study regarding prevention of COVID 19 supported the stated hypothesis that heath should be provided for all pregnant educational intervention is effectively women at all MCH centers until the total improving pregnant women knowledge, management of COVID 19 virus. attitude and practice regarding prevention 2. Antenatal heath care should have a of COVID 19. plan to communicate online with pregnant women to mange such these crisis Recommendation: situations.

276 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

Limitation of the Research Bouaziz, J., Even, M., Bogillot, F., The current research study has some Vesale ,E., Nikpayam ,M., limitations, as follow: Mihalache ,A., Krief , D., Frydman ,R and Ayoubi, J. COVID-19 in Firstly, the lack of national and pregnancy: What do we really international researches that study the know?F1000Research 2020; current research topic. 9(362):Page 3 of 16.

Thirdly, sometimes the sessions Centers for Disease Control and Prevention (CDC). CDC updates were protracted due to noise and other COVID-19 transmission webpage to individuals’ interruption and lastly, clarify information about types of challenging to facilitate group place and spread 2020; Available at sessions. https://www.cdc.gov/media/releases/202 0/s0522-cdc-updates-covid- Acknowledgments transmission.html. Accessed on 5/7/2020 The authors are very much grateful to all women who participated in this Chen N, Zhou M, Dong X, Qu J, Gong F, study for their kind and effective Han Y, et al,(2020): Epidemiological cooperation. The authors also grateful to and clinical characteristics of 99 cases the directors of maternal and child health of 2019 novel coronavirus pneumonia in centers for their support. Wuhan, China: a descriptive study. Lancet. 395: 507-13. Financial support Collin J, Byström E, Carnahan A, Ahrne No funding was received M. Pregnant and postpartum women Conflict of interest with SARS-CoV-2 infection in intensive care in Sweden. Acta Obs Gynecol No Scand. 2020 May 9;99(7):819–22.

References: Daniel Bekele, Tadesse Tolossa, Reta Tsegaye, Wondesen Teshome.The knowledge and practice towards Ajilore K, Atakiti I, Onyenankey K. COVID-19 pandemic prevention among College students’ knowledge, attitudes residents of Ethiopia: An Online Cross- and adherence to public service Sectional Study2020; medRxiv or announcements on Ebola in Nigeria: bioRxiv , Suggestions for improving future Ebola doi: https://doi.org/10.1101/2020.06.01. prevention education programmes. 127381. Health Education Journal. 2017; 76: 648-60. Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Bao-Liang Zhong, Wei Luo, Hai-Mei Li, Zambrano LD, et al. Characteristics of Qian-Qian Zhang, Xiao-Ge Liu, Wen- Women of Reproductive Age with Tian Li, Yi Li, Knowledge, attitudes, Laboratory-Confirmed SARS-CoV- and practices towards COVID-19 2.2020; Weekly / June 26, 2020 / among Chinese residents during the 69(25);769–775 Morbidity and rapid rise period of the COVID-19 Mortality Weekly Report outbreak: a quick online cross-sectional (MMWR).available at : survey. Int. J. Biol. Sci. 2020; 16(10): 1745-1752. doi: 10.7150/ijbs.45221. 277 Original Article Egyptian Journal of Health Care, 2020 EJH vol. 11 no. 4

https://www.cdc.gov/mmwr/volumes/69 Coronavirus 2019-nCoV (SARS-CoV-2) /wr/mm6925a1.htm Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Jiao J, Tang X, Li H, Chen J, Xiao Y, Li Coronavirus Infections. Viruses 2020; A, et al. Survey of knowledge of 12(2), villagers in prevention and control of 194; https://doi.org/10.3390/v1202019 SARS in Hainan Province. China 4. Tropical Medicine. 2005; 5: 703-5. Tachfouti N, Slama K, Berraho M, Karimi-Zarchi,M., Neamatzadeh, H., Nejjari C. The impact of knowledge Abbasi, H. , Mirjalili, S., Behforouz, and attitudes on adherence to A., Ferdosian, Fand Bahrami, tuberculosis treatment: a case-control R.Vertical Transmission of Coronavirus study in a Moroccan region. Pan Afr Disease 19 (COVID-19) From Infected Med J. 2012; 12: 52. Pregnant Mothers to Neonates: A Review. Fetal Pediatric Pathology 2020; Tao N. An analysis on reasons of SARS- 39(3):246-250. doi: induced psychological panic among 10.1080/15513815.2020.1747120. students. Journal of Anhui Institute of Education. 2003; 21: 78-9. Madappuram, N and Kamel, H. Covid19 and Pregnancy.Annals of neonatology The Novel Coronavirus Pneumonia journal 2020 ; 2 (2):3 ISSN: 2636-3596, Emergency Response Epidemiology DOI:10.21608/ANJ.2020.29120.1011 Team ,(2020): The epidemiological characteristics of an outbreak of 2019 Miller, R. Transmission and risk factors of novel coronavirus diseases (COVID-19) COVID-19. Cleveland Clinic Journal of in China. Chin J Epidemiol. 41: 145-51. Medicine, 2020; Available at https://www.ccjm.org/content/early/202 World Health Organization. (2020): 0/05/12/ccjm.87a.ccc029. Accessed on About COVID 19. 5/7/2020. Available :athttp://www.emro.who.int/h ealth-topics/corona-virus/situation- Nwafor, J., Aniukwu,J., Anozie, O., reports.html . Accessed on4/7/2020. Ikeotuonye, A.Knowledge and practice of preventive measures against COVID- Yassa,M ., Birol,P., Yirmibes,C., Usta,C., 19 infection among pregnant women in Haydar,A., Yassa,A., Sandal,K., a low-resource African setting. Tekin, A & Tug, N.Near-term pregnant Researchgate 2020; DOI: women’s attitude toward, concern about 10.1101/2020.04.15.20066894 :Availabl and knowledge of the COVID-19 e at pandemic, The Journal of Maternal- https://www.researchgate.net/publicatio Fetal & Neonatal Medicine2020;DOI: n/340788790. 10.1080/14767058.2020.1763947. ISSN: 1476-7058 (Print) 1476-4954 (Online) Person B, Sy F, Holton K, Govert B, Journal homepage: Liang A, National Center for Inectious https://www.tandfonline.com/loi/ijmf20. Diseases SCOT. Fear and stigma: the epidemic within the SARS outbreak. Zhang X, Sun Y, Ye D, Sun Z, Su H, Ni J, Emerg Infect Dis. 2004; 10: 358-63. et al. Analysis on mental health status of community residents in Hefei during Schwartz D A & Graham AL. Potential SARS spread. Chin J Dis Contr Prev. Maternal and Infant Outcomes from 2003; 7: 280-2.

278