Effect of Guideline Protocol Regarding COVID-19 Preventive Measures on Awareness of Hospitalized School Age Children

Background: Lack of awareness about the fast-spreading coronavirus disease 2019 (COVID-19) pandemic represents a global threat. There is growing evidence of the challenges with adherence to COVID-19 prevention measures and the effect of the prevention measures on the health of populations especially those with comorbidities. Aim of the study: was to evaluate the effect of guideline protocol regarding COVID-19 preventive measures on awareness of hospitalized school age children. Subjects and Method: Research design: One group pre-posttest quasi-experimental design was adopted to carry out this study. Setting: The study was conducted in the medical wards at Zagazig University Pediatric Hospital, Zagazig, Egypt. Subjects : 72 hospitalized school-aged children. Tools of data collection: Structured Interview Questionnaire to collect data about studied children characteristics and evaluate their awareness regarding COVID-19 preventive measures. Results: The study reveals that 2.8% of the studied group had satisfactory general awareness score before the guideline protocol compared to 98.6% post the protocol with highly statistically significant difference at (P<0.001) throughout study phases. Conclusion: The guideline protocol regarding COVID-19 preventive measures for hospitalized school age children had great effect on improving their awareness. Recommendations: Pediatric nurses must provide awareness and public knowledge regarding the novel COVID-19 with simple Arabic illustrative educational booklets, pictures and videos about COVID-19 for all children in all health care settings to prevent the spread of this pandemic disease.


Introduction
The coronavirus disease of 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was first emerged in the Wuhan province of China, in December 2019.SARS-CoV-2 is a 30 kilobase enveloped singlestranded RNA virus that has been the third beta coronavirus pandemic after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) (1) .
Coronavirus Disease 2019 (COVID-19) is spreading rapidly around the world with devastating consequences on patients, health care workers, health systems, and economies (2) .Covid-19 has been shown to attack humans of all ages ranging from adults to children (3) .As of May 10, 2022, more than 2,7107825 confirmed cases and more than 1,877 deaths have been reported globally among children aged 5 to 14 years (4) .Children and adolescents under 20 years of age account for 33% of the 2020 population, 21% of the reported COVID-19 cases, 0.4% of the reported COVID-19 death (5) .
Egypt is one of the lower-middleincome countries with limited resources which require a simple and practical preventive guideline to reduce the spread of COVID-19 pandemic among children with comorbidities, as well as to protect health care workers from catching infection (6) .
Compared with adults, children and adolescents who are infected with SARS-CoV-2 are more commonly asymptomatic or have mild, nonspecific symptoms.Similar to adults with SARS-CoV-2 infections, children and adolescents can spread SARS-CoV-2 to others when they have no symptoms or have mild, non-specific symptoms (7) .This is quite alarming and risky for all population who comes in close contact to the asymptomatic COVID-19 cases.
Children are less likely to develop severe illness or die from COVID-19.However, a high proportion of the fatal cases of pediatric COVID-19 are in children with underlying medical conditions, most commonly chronic lung disease, obesity, and neurological and developmental disorders (8) .
The primary mode of transmission of SARS-CoV-2 is via exposure to respiratory droplets carrying the infectious virus from close contact or droplet transmission from infected (9) .SARS-CoV-2 can also be transmitted longer distances through the airborne route, but the extent to which this mode of transmission has contributed to the pandemic is unclear (10) .The Centers for Disease Control and prevention stated that individuals can be infected with SARS-CoV-2 via contact with surfaces contaminated by the virus, but the risk is low and is not the main route of transmission of this virus (7) .
The symptoms of COVID-19 are alike in children and adults, but the frequency of symptoms differs (11) .COVID-19 appears to be milder in children than in adults, but severe cases have been reported in children (12)   .Fever and cough are the most common reported other findings were nausea/vomiting, diarrhea, dyspnea, nasal symptoms, rashes, fatigue, abdominal pain, Kawasaki-like signs, neurologic symptoms, conjunctivitis, and pharyngeal erythema (13) .
COVID 19 is evolving science and lot of research are in progress regarding characteristics of the virus and its treatment.Hence prevention plays a major role to fight the spread of infection.This can be achieved by education and training.The golden rules to fight against the spread of infection are frequent hand hygiene, respiratory and mask etiquette, social distancing.Although 80-90% COVID positive are mild and can be managed with home isolation still it's not possible due to poor housing condition in a densely populated country like Egypt.Mild and asymptomatic cases in the community remain undiagnosed and act as a super spreader affecting a wide majority of susceptible and vulnerable population (14) .Hence, this study was undertaken with the objective to improve awareness of hospitalized school age children regarding COVID-19 and its preventive measures.

Significance of the Study:
While most children have had mild or no symptoms, thousands have died.Children with underlying medical conditions are more likely to experience severe effects of COVID-19, but even healthy children can be severely affected.Children can spread COVID-19 to others and can have long-term effects that last months.For these reasons, children need to be protected from COVID-19 Therefore, this study aimed to develop guideline protocol regarding COVID-19 preventive measures to upgrade awareness of hospitalized school age children.

Aim of the study:
The aim of the study was to evaluate the effect of guideline protocol regarding COVID-19 preventive measures on awareness of hospitalized school age children.

Research questions:
 What is the level of awareness among hospitalized school age children regarding preventive measures of COVID-19? Does guideline protocol regarding COVID-19 preventive measures enhance awareness of hospitalized school age children?

Subjects and Methods:
Research design: One group pre-post test quasiexperimental design was adopted to carry out this study.

Study Setting:
The study was conducted at pediatric hospital at Zagazig University Hospitals, Egypt.

Study Subjects:
A purposive sample composed of 72 school age children attending the previous setting and their parents who accepted to participate in the current study according to the following criteria: Inclusion criteria: Age: from 6 to 12 years, Sex: both sexes and didn't suffer from coronavirus during data collection.

Exclusion criteria:
Any child with conditions that interfere with the cognitive or physical ability of the child (down syndrome, disturbed level of consciousness, ADHD, developmental delay, etc.).The sample size was determined to be 72 by applying for the "Open Epi software package" program, at confidence interval 95% and power 80%.

Tool for data collection:
In order to fulfill the objectives of the study A Structured interview questionnaire was used to collect necessary data.

Scoring system:
Scoring system for awareness assessment was 51 scores.Each right answer obtained one score, and the wrong answer or no response received a score of zero.The total score was converted to 100% and then categorized as follows: the total score of awareness less than 50% (less than score of 25.5) was considered as unsatisfactory while a score of 50% and more (score of 25.5) was considered as satisfactory level of awareness.

Content Validity and Reliability:
Content validity for the tool was established by a group of the panel who were three specialists from nursing faculty staff who revised the tool and ascertained its clarity, significance, and comprehensiveness.Accordingly necessary modifications were done.Testing reliability of the proposed tool was done by Cronbach's Alpha test, it was (0.75).

Guideline protocol Development:
Guideline protocol was developed to educate hospitalized school age children about COVID-19 preventive measures.

Aim of the Guideline protocol:
The During this phase, the researcher reviewed local and international literature and a pilot study was carried out on 10% of hospitalized school age children (7 children).
( 2 ) Planning phase: Based on the results obtained from the assessment phase, pilot study and reviewing the related relevant literature, the protocol was developed by the researcher.Detected needs, requirements and deficiencies were translated into aims and objectives of the guideline protocol in the form of a booklet .
Various teaching methods were selected to suit teaching individually in a form of lectures, group discussion, and role play.Teaching media were prepared as handout (booklet), and colored posters, as well as video tapes.
(3) Implementation phase: After interviewing the hospitalized school age child (pretest), The guideline protocol was implemented through two sessions in which each school age child was interviewed separately to facilitate the learning process in a way that meets the educational needs of each child.The length of each session varied according to the content, time available and the school age child's response and ranged from 20-30 minutes.Sessions were explained in simple Arabic language that suits the level of the studied school age children's understanding.Motivation and reinforcement during each session were used to enhance children's active participation and foster learning.

(4) Evaluation of the impact of the intervention
The studied school age children were re-interviewed after one week of implementing the guideline protocol and reassessed (post-test) using the same measurements (Tools) used in the pre-test to answer the current research questions.

Field work:
Data collection took a period of 4 months from November 2021 to February 2022.The researcher attended the study settings two days/week for data collection and implementation of the guideline protocol.
After identifying the subjects who fulfilled the criteria of the study, the researcher started with explaining the aim and process of the study briefly and obtained oral consent from parents of every hospitalized school age child who were willing to participate.The researcher also, determined the place of meeting and timetable.Each hospitalized school age child was interviewed individually in the presence of his/her parent to collect the necessary data (personal and medical history), assess their awareness regarding COVID19 and its preventive measures (pretest) which took 10-20 minutes.During the first session the researcher educate the school age child about COVID19, its origin, signs and symptoms, mode of transmission, and high risk people.Second session was after 20-30 minutes break and involved educating about COVID19 preventive measures as hand hygiene, cough etiquette and using a face mask.
Assessment of the hospitalized school age children' awareness regarding preventive measures of COVID-19 were reassessed after one week of the intervention using the same tool (posttest).

Pilot study:
Pilot study was conducted on 7 (10 %) of children and they were excluded from the total number of students to insure the clarity and comprehensiveness of the tool.

Administration and Ethical consideration:
This study was approved by the Ethics Committee of Zagazig University.To carry out the study in the selected setting, an official permission was obtained from the director of Zagazig University Hospitals for data collection.
All ethical issues were taken into consideration during all phases of the study, the aim and process of the study was explained to every hospitalized school age child and an oral consent was obtained from those who accepted to participate in the study.The researcher emphasized on the patient's right to withdraw from the study at any phase; also provided assurance of maintaining an anonymity and confidentiality of the patients' data that used for the research purpose only.

Statistical Analysis:
All data were collected, tabulated and statistically analyzed using SPSS 20.0 for windows (SPSS Inc., Chicago, IL, USA 2011)).
Quantitative data were expressed as the mean ± SD, median (range) and qualitative data were expressed as absolute frequencies (number) & relative frequencies (percentage).Mc nemar test was used to compare between two dependent groups of categorical data.Wilcoxon signed ranks test was used to compare between two dependent groups of non-normally distributed variables.Percent of categorical variables were compared using Chi-square test or Fisher's exact test when appropriate.Cronbach alpha coefficient was calculated to assess the reliability of the scales through their internal consistency.P-value < 0.05 was considered statistically significant, pvalue < 0.01 was considered highly statistically significant, and p-value ≥ 0.05 was considered statistically nonsignificant (NS).

Results:
Figure (1) illustrates that 60% of the study group did not know people who had COVID-19 before.

Discussion:
A global pandemic requires a global effort to end it, none of us will be safe until everyone is safe (51) .Egypt is one of the biggest countries in the Arab region, Africa, and the Middle East.With more than 100 million citizens, Egypt is among the most populous countries in Africa (16) .This high number of citizens could be associated with a great risk of spread and mortality, especially among those with chronic diseases.High proportion of the fatal cases of pediatric COVID-19 are in children with underlying medical conditions, most commonly chronic lung disease, obesity, and neurological and developmental disorders (17) .Here comes the importance of educating children, especially in hospitals, on COVID-19 and ways to prevent it.
Results of the present study revealed that more than one third of the studied children ranged in age from 10-12 years with a mean of 8.82 ± 1.95 years.In relation to gender, the results showed that more than half of the studied children were boys compared to less than half were girls.According to Finelli et al. (18) , data regarding the gender-based differences in COVID-19 suggests that male patients are at risk of developing severe illness and increased mortality due to COVID-19 compared to female patients.Nearly the same results were found in Nafee et al. (19) , Amer and Mohamed (20) , and Shaikh and Likhite (21)   .Also, these results were consistent with Xue et al. (22) who conducted a study of Knowledge, attitudes, and practices towards COVID-19 among primary school students in Hubei Province, China .
Regarding the common source of information on COVID-19 among the studied school age children.It was found that family represented a common source of information for more than three quarters of the studied children and then TV, which represented a common source of information for nearly three-fifth of the studied children.These results were consistent with YILDIZ (23) who conducted a study of Determining the level of knowledge regarding COVID-19 and protection measures of children between aged 8-12 years in Turkey and found that children learned their knowledge on COVID-19 generally from television or families.These results disagreed with Elsakka and Khalil (24) who reported in their study about Knowledge, perception and practice of children and adolescents towards COVID-19 pandemic in Egypt that social media was the most common source of information about COVID-19 .
The family as the main source of information in the current study could be explained in the light of its results.As more than half of the fathers of the studied children had a university education, while more than three quarters of their mothers had a secondary or university education, which made them able to educate their children and make them aware of this pandemic.In addition to TVs which are more available in all Egyptian homes, especially the countryside, than social media.
In response to the current pandemic, child psychologists and health scientists have joined forces with, educators, artists, and writers to produce innovative communication materials which ranged from children's books, videos to infographics and comics.Those are a powerful way to teach kids about COVID-19 (19) .
This study illustrated that the highest percentage of the studied children, nearly two quarters, opted video as the preferred method to learn about COVID-19 followed by booklet, picture, and the least one was lecture.These results were consistent with Shaikh and Likhite (21) who conducted a study about Awareness, perception and safety practices about COVID-19 in school children of 6-16 years using COVID-19 quiz in India and found that more than half of children would prefer to get information in pictures/video form, while less than the fifth opted lectures and information from parents/teachers.New information can be represented in the form of children friendly videos, cartoons, or pictures so that they are kept well aware of new advances regarding COVID-19.
WHO (25) define Coronavirus (Covid-19) as a virus that causes respiratory tract infections, ranging from the common cold to serious illnesses.This definition was reported by nearly two-thirds of the studied children before implementation of guideline protocol which improved after implementing the protocol.Statistically significant difference was found throughout study phases.
From the researcher's point of view, the children's knowledge of what the Corona virus is, was a result of the rapid spread and the world's fear of the epidemic that dominated in a few days in several countries.On the other hand, the higher score may be because the children were asked whether this definition is true or false and were not asked to mention the definition themselves.
These results were in harmony with Karunakaran and Gheena (26) who conducted a study about awareness related to the spread of Covid-19 to children in India and found that more than half of children were aware about COVID-19 .
These results disagreed with Nafee et al. (19) who conducted a study about Effect of a comic story on orphan children's knowledge and hand washing practice about pandemic of COVID-19 in Egypt and stated that all children' information about COVID-19 definition were incorrect or incomplete correct answer pre comic story implementation comparing to correct and complete answer post comic story implementation .
The knowledge of children in the current study in relation to symptoms of COVID-19 was not complete before the conduction of the guideline protocol.The most reported symptoms before intervention were fever and cough.These findings could be explained by the fact that fever and cough are the most common reported symptoms for COVID-19 (13) .In the same context, Amer and Mohamed (20) who conducted a study about Effect of nursing instructions about COVID-19 preventive measures on knowledge and reported practice of hospitalized school age children in Egypt and found that knowledge of hospitalized school age children in relation to symptoms of COVID-19 was not complete before the conduction of the nursing instruction.
The results of the current study revealed that after applying the guideline protocol, school age children were knowledgeable about the prominent symptoms of COVID-19 like fever, cough, fatigue, shortness of breath, loss of taste or smell, sore throat, headache, diarrhea, and muscle pain, more than half of the studied children gave a complete correct answer.Statistically significant difference was found throughout study phases.This improvement can be attributed to the guideline protocol in which the children were trained.
Moreover, in relation to COVID-19 modes of transmission, the present study revealed that nearly two thirds of the studied children reported droplets from sneezing or coughing as the main mode of transmission while only onefifth reported that touching contaminated surfaces could spread COVID-19.There was statistically significant improvement in studied children awareness regarding mode of transmission post intervention (P=0.001).
In the same line, Abdelhafiz et al. ( conducted a study about Knowledge, perceptions, and attitude of Egyptians towards the novel Coronavirus disease (COVID-19) and their results showed that the most reported mode of transmission was droplets from cough and sneezing by infected person followed by surfaces touched by affected person .
These findings could be explained by the fact that the primary mode of transmission of SARS-CoV-2 is via exposure to respiratory droplets carrying the infectious virus from close contact or droplet transmission from presymptomatic, asymptomatic, or symptomatic individuals harboring the virus (9) .On the other hand, The Centers for Disease Control and prevention (28) stated that individuals can be infected with SARS-CoV-2 via contact with surfaces contaminated by the virus, but the risk is low and is not the main route of transmission of this virus.
These results were inconsistent with Ferdous et al. (29) who conducted study about Knowledge, attitude, and practice regarding COVID-19 outbreak in Bangladesh and found that the most reported mode of transmission was close contact with an infected person (93.7%).Amer and Mohamed (20) also reported that more than half of children believed that COVID-19 could not be transmitted through coughing and sneezing, while more than three quarters were not aware about transmission through contact with contaminated object or surface.
Vaccines to prevent SARS-CoV-2 infection are considered the most promising approach for curbing the pandemic (30) .In Egypt, a vaccine is available to prevent COVID-19 for people 12 years and older (31) .
Concerning vaccine availability, the current study revealed that most of the studied children were aware of the availability of vaccination for COVID-19.While about half of them were aware that it was not yet available for children under 12 years old in Egypt.These results could be attributed to the great efforts made by the Egyptian government to make the vaccine available and to educate Egyptians about its importance in reducing this pandemic through the media, health convoys and health units.
Also, this was in the same line with Vatovec and Hanley () in their study about awareness, attitudes, and compliance with COVID-19 measures among Vermont residents who stated that more than half of respondents were aware about availability of safe and effective vaccine for COVID19 reporting that vaccination is the most effective way to prevent COVID-19 and its complications.
In the face of this epidemic, the whole world has made huge efforts to cope with this disease (30) .For that WHO (33) has advised hand hygiene, masking, physical distancing, respiratory etiquette, avoiding touching the face, adequate ventilation of indoor spaces, cleaning and disinfecting objects and surfaces that are frequently touched for protection from this infection.
Nearly three quadrants of the studied children were aware about masking and hand hygiene precautions before intervention compared to all of them post intervention.This is a very good improvement and an assuring sign that they would be able to keep themselves safe in community.
In the same line, Shaikh and Likhite (21) reported that nearly all participants of the survey answered as " Yes" for these safety measures.Moreover, Matovu et al. (34) in their study about COVID 19 awareness, adoption of COVID 19 preventive measures, and effects of COVID 19 lockdown among adolescent boys and young men in Kampala, Uganda found that more than 85% of the studied children were aware about masking and hand hygiene precautions .
These results could be explained by the fact that in the current state of the COVID-19 threat, permanent hand hygiene combined with mask-wearing is an approach that has been proven to slow the spread of the virus (35) .
Concerning physical distancing, more than one third of the studied children were aware of physical distancing as a preventive measure for COVID-19 pre intervention compared to nearly all of them post intervention.This result was in harmony with Wasave et al. (36) who conducted a study about Knowledge, awareness, and practices towards COVID-19 among the marine fishers of Maharashtra State of India and found nearly the same result.
These results disagreed with Matovu et al. (34) who found that 70% of the participants was aware about social distancing as a preventive measure for COVID-19.Moreover, Roy et al. (37) who conducted a Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic and found that most of the participants (more than 4/5th) agreed with social distancing.
The result of the current study was explained by the fact that Egyptians were not strictly practicing social distancing to prevent transmission of COVID 19 (38) .
Regarding other preventive measures, it was found that low percentage of the studied children was aware about cough etiquette, good ventilation, avoiding travel across cities with high COVID-19 transmission rates, avoiding people with symptoms such as cough and fever, and avoiding crowded places as well as avoiding touch to face with unwashed hands and staying home if having symptoms.There was a marked improvement in children's awareness regarding those preventive measures after implementation of the guideline protocol.This difference was highly statistically significant (P<0.001) and could be attributed to the guideline protocol in which the children were trained.
These results were consistent with Amer and Mohamed (20) who reported that more than half of the school age children were not alert to the hazard of touching the face, and not sneezing into their elbow or tissue.Majority of the participants were knowledgeable about coughing and sneezing etiquette after nursing instructions.Moreover, Matovu et al. (34) reported that less than one quadrant of the respondents reported that avoiding touching the mouth, eyes and nose with unwashed hands was a COVID-19 prevention measure .
On the contrary, Shaikh and Likhite (21) found that most of the studied children believed that covering mouth while coughing or sneezing, not touching mouth, nose, eyes, and face, staying away from those who have cough or fever are Safety measures for preventing COVID-19.From the researchers' point of view, the behavior of the children was very normal and can be explained as the practice of coughing or sneezing into elbow was not well known among people before COVID-19.
The disease is spreading rapidly and new cases being found every day.Hence, it is important for children to know how to behave in case a family member is infected or if they are home quarantined.CDC (39) Guidelines for such scenarios are isolation, proper masking, hand hygiene, good ventilation, and sanitization to be the best strategy for safeguarding oneself.
When asked about safety precautions about the same before the guideline protocol, most of children reported that they would wear a mask and avoid direct contact with the infected person.About one third of them chose to avoid sharing personal items and wash hands more frequent.While other precautions including maintaining more than 6 feet distance, not touching face with unwashed hands, surface sanitizations, wearing gloves, and limiting visitors were unknown for majority of the studied children .
In the current study, the studied children's awareness improved significantly post intervention, as more than two-thirds of them knew all the safety precautions regarding how to deal with an infected family member.These findings could be explained by the fact that interventions such as social distancing, masking, and hand hygiene have been the primary preventive strategies to avoid infection with SARS-CoV-2 (40) .This result goes in the same line with Naser et al. (41) who conducted a study of Knowledge and practices during the COVID-19 outbreak in the Middle East and found nearly the same result regarding direct contact with the infected person.On the contrary disagreed with Abdelhafiz et al. (27) who reported that most of the participants agreed with maintaining an appropriate distance from anyone with symptoms.
The results of the current study displayed that there was marked enhancement in studied children total awareness score after the application of the guideline protocol.The total score of general awareness increased from less than three percent pre intervention to more than ninety eight percent post intervention.The difference was highly statistically significant (P<0.001).
This Finding agreed with Athira Krishnan et al. (42) who conducted a study on Developing communication tools for creating awareness of COVID-19 pandemic among school going children in Kerala and reported that Significant difference was found in the level of awareness about the COVID-19 among children post intervention.Moreover, this result was consistent with Nafee et al. (19) who found that the implementation of a comic story had improved children's total score of knowledge regarding COVID-19 with statistically significant differences in relation to pre and post comic story implementation The significant change in the studied children awareness score after implementation of the intervention in the current study may be occurred due to the nature of the guideline protocol.In which several teaching methods were used to import knowledge about the disease and its preventive measures including educational sessions, booklet, pictures, and videos .
The Covid-19 virus was a pandemic devastated within a short period to many parts of the world.Effective and efficient controlling of the pandemic requires strict adherence to precautionary measures.

Conclusion:
Based upon the findings of the present study, it could be concluded that the guideline protocol regarding COVID-19 preventive measures for hospitalized school age children had great effect on improving their awareness regarding COVID-19 and its preventive measures

Recommendation:
Based on findings, the study recommended:

Figure ( 2
Figure (2) represents preferred method to learn about COVID-19.43% of the children reported they would prefer to get information in a video form.

Figure ( 3
Figure (3) represents common source of information regarding COVID-19 among the studied school age children.It was found that family and friends represented a common source of information for 83.3% of the studied children.

Table ( 1
) shows characteristics of the studied school age children.Regarding the age, it was found that 37.5% of the studied children aged from 10 to 12 years with a mean age 8.82 ± 1.95 years.Concerning gender, 52.8% was males.It is revealed from the same table that 87.5% of the studied school age children was students.Studied school age children from rural areas represented 73.6%.It was found also that 94.4% of the studied children lived with a crowding index of two or less.Regarding the length of stay, it was found that 43% of the studied children was hospitalized for two days or less with a mean length of stay 6.46± 8.44 days.

How to deal with the side effects of anti-COVID-19 vaccines?
More than one answer, MC: Mcnemar test, **: statistically highly significant (p<0.001).

): Children's Knowledge regarding self-protection against household infected person throughout study phases (n=72). MC p-value Study phase Items Post Pre % No. % No. What do you do if a member of the household is infected with COVID-19 to limit the spread of infection? 
More than one answer, MC: Mcnemar test, **: statistically highly significant (p<0.001).