key: cord-0780962-ttw7t3an
authors: Zengin, Mürşide; Yayan, Emriye Hilal; Vicnelioğlu, Elanur
title: The effects of the COVID‐19 pandemic on children's lifestyles and anxiety levels
date: 2021-04-01
journal: J Child Adolesc Psychiatr Nurs
DOI: 10.1111/jcap.12316
sha: a990d0aef579d750dc00012091a09a544e63f981
doc_id: 780962
cord_uid: ttw7t3an

OBJECTIVE: This study was conducted to determine the effects of the coronavirus disease 2019 (COVID‐19) pandemic on children's lifestyles and anxiety levels. METHODS: This study was designed as a descriptive, cross‐sectional online questionnaire survey. RESULTS: Of the children, 91.9% reported that the pandemic had an important effect on their lifestyle. Children stated that they experienced changes in terms of nutrition, sleep, television‐internet use, social activity, coursework time, and school success due to the pandemic. IMPLICATION FOR PRACTICE: It was determined that the COVID‐19 pandemic caused changes in children's routines, and the children experienced moderate or high levels of anxiety. Primary healthcare providers should increase their attention to these issues to protect and improve children's mental health during the pandemic period.

In December 2019, a novel coronavirus disease 2019 emerged in Wuhan, Hubei Province, China. The disease spread worldwide before officially being declared a global pandemic by the World Health Organization on March 11, 2020 (Hong et al., 2020; Huang et al., 2020; Wang, Pan, Wan, Tan, Xu, McIntyre, et al., 2020) .

COVID-19 results in high levels of morbidity and mortality (Rundle et al., 2020) .

Pandemics can result in unbearable psychological pressure along with the physical disorder associated with the infection . During this period, children are constantly exposed to news about the pandemic (Guan et al., 2020) ; media and social conversations are completely dominated by the outbreak. Children are exposed to large amounts of information, high levels of stress and anxiety transmitted through the surrounding adults (Dalton et al., 2020) .

The outbreak could cause serious changes in the lifestyle of the pediatric population (Filipova et al., 2020; Hadley, 2020) . Social isolation and home-living practices interrupt children's physical activity levels Rundle et al., 2020) . In this process, changes occur in children's routines. While the education and friendships of children are interrupted, many also experience real anxiety and fear (Hadley, 2020) . Pandemic and home isolation also cause a change in children's eating habits (Rundle et al., 2020; Wang, Zhang, et al., 2020) , and their social infrastructure is completely affected (Dalton et al., 2020) .

Due to the lower incidence of infection and mortality than adults, professionals may be less focused on the unique clinical features of COVID-19 and mental health status in children (Ma et al., 2020) . There are a limited number of studies on the psychological effects of the pandemic in children and adolescents (Lee, 2020) . However, evidence has shown that children and adolescents who experienced disasters might suffer from greater stress and trauma because of the lack of development of proper emotional reactions and coping techniques (Duan et al., 2020) . Identifying psychological problems experienced during the pandemic is important in terms of reducing symptoms and developing evidencebased strategies . This study was conducted to determine the effects of the COVID-19 pandemic on children's lifestyles and anxiety levels. The study population consisted of children between the ages of 9 and 12 residing in a south-eastern Turkish province. During the study, the government was implementing some coronavirus measures, such as the complete closure of schools (distance learning) and a partial or fulltime curfew for children under the age of 20. The sample size was calculated as 309 children (https://www.surveysystem.com/) with a 95% confidence level, 5% confidence interval, and an 1585 study population (number remaining after the villages and municipalities of the designated region have been removed). In the study, the purposive sampling method was used, and the data were collected with children in a central district in the province determined in terms of having similar socio-demographic and cultural characteristics.

Parents of 9-12 years old children attending primary schools in the designated region were reached via a social communication application and a link to the informed consent and questionnaire forms were sent to their mobile phone. The questionnaire form continued to be sent to potential participants until the calculated necessary sample size was reached. In the first stage, the questionnaire form was sent to 425 parents; 342 of these were returned by parents (return rate: 80.4%). Thirty-three questionnaires that were incomplete or incorrectly completed, or did not meet the inclusion criteria were excluded from the study (attrition rate: 9.6%). The inclusion criteria of the study follow: (1) children aged 9-12 years old;

(2) living in the designated city; and (3) volunteering to participate after being informed about the study. Children (1) who did not complete the questionnaire entirely; and (2) who were diagnosed with any mental disorders were excluded from the study. Chosen by the purposive sampling method, the final study sample consisted of 309 children who met the inclusion criteria and completed the questionnaire.

The questionnaire form used in data collection had two parts:

the first entitled the introductory information form consists of 22 questions to determine the sociodemographic characteristics of children (age, gender etc.) and the changes in their lifestyle (nutrition, sleep, television-internet use, social activity etc.) during the COVID-19 pandemic. To evaluate the children's anxiety levels, the second part included the state-trait anxiety inventory for children (STAIC) . After the data collection form was prepared by the researchers, it was sent to three specialists who are also lecturers in Children's Health and Diseases Nursing for their review. The form was finalized by making the necessary corrections in line with the suggestions from the experts.

The STAIC was developed by Spielberger and Edwards in 1973 and adapted to Turkish by Özusta in 1995. It consists of two sub-scales (with 20 items each) that separately assess the child's level of state and trait anxiety. Children are asked to assess how they feel "at the moment" for the state anxiety inventory (SAI), and how they "generally" feel for the trait anxiety inventory (TAI). The total score of each subscale varies from 20 to 60. Higher scores indicate higher levels of anxiety. The Cronbach's alpha coefficient was found to be 0.82 for the state anxiety subscale, and 0.81 for the trait anxiety subscale, in a study conducted with 615 healthy children (Özusta, 1995) . In this study, Cronbach's alpha was 0.87 for the SAI and 0.89 for the TAI.

A pilot study was conducted with 20 children to determine the validity of the data collection tools. In the pilot study, the adequacy and clarity of the questions created by the researchers to determine the changes in the lifestyles of the children during the pandemic were evaluated. The data obtained from the pilot study were not used due to corrections on the questions after the pilot study. The data collection form was transferred to an online format. The online environment was used for the collection of data owing compliance with isolation and quarantine suggestions during the pandemic as well as consideration of the efficiency of the data collection process and the ability to reach remote individuals.

The link address was shared with parents who have children between the ages 9 and 12 and it was requested that they complete the form with their children. As noted, parents were sent the consent and questionnaire via mobile phone. Before completing questionnaires, all participants and their parents were debriefed on the study purpose and contents. Once consented, participants filled out the set of questionnaires online. We also included our email addresses and phone number to the first page of questionnaires so that participants could consult and interact with us at any time. Children were to complete the form with the help of their parents. The data collection form was completed in an average of 10 min by participants.

Data were analyzed using the IBM SPSS Version 23 package program (IBM Corp.) . The data analyzes were performed using descriptive and comparative analysis methods. For descriptive statistics, mean, standard deviation, frequency and percentage distribution were used. Shapiro-Wilk test was implemented to determine whether the sample data were normally distributed. From comparative statistics, independent groups t test, analysis of variance, and the Kruskal-Wallis test were used for comparing the anxiety levels of children considering select variables (age, gender, difference in games, change in communication with friends). The findings obtained were interpreted at a 95% confidence interval at a significance level of 0.05. 

The average age of the children in the study was 10.3 ± 1.2; 52.1% of participants were male. It was determined that 82.2% of the children lived in a nuclear family, and 75.4% had middle income. Some sociodemographic characteristics of children and parents in the study are provided in "meeting with friend," "leaving home," and "hugging their loved ones."

The mean anxiety scores of the children were 43.44 ± 6.80 for the SAI and 34.84 ± 7.75 for the TAI. A comparison of the STAIC levels of children in terms of select variables is provided in Table 3 . According to the table, as the age of the children increased, the state anxiety levels decreased and the trait anxiety levels increased (p < .05). While the state anxiety levels of boys were determined to be significantly higher than girls', there was no difference between the genders in terms of the trait anxiety score. The state anxiety levels of children who said they play more creative games at home and the trait anxiety levels of children who said that there was no one to play with were found to be higher compared to other participants. The state anxiety score of children who could easily contact their friends on the Internet and the trait anxiety score of children who could never contact their friends since pandemic were found to be significantly higher than the other participants.

Little is known about changes in the levels of psychological impact, stress, anxiety, and depression during this pandemic outside of China . Changes in children's lives along with differences in parental behaviors due to the pandemic may be perceived as a threat by the child and cause anxiety (Dalton et al., 2020) .

In our study, we also examined the state/trait anxiety levels of study conducted with a large sample, it was found that the participants experienced moderate or severe stress, anxiety and depression during the pandemic (Wang, Pan, Wan, Tan, Xu, McIntyre, et al., 2020) .

Despite children seeming to have more positive outcomes in relation to the physical progression of COVID-19 they should still be classed as a vulnerable group during the pandemic for several reasons. One they are being exposed to a process that they have not experienced before and two they are often hearing about illness and death. Also, as part of the measures taken to prevent the spread of the virus, children are kept at home for long periods and are forced to stay away from their school and friends (Jiao et al., 2020) . In this study, it was determined that staying away from friends was related to an increase in the children's trait anxiety level. It was also determined that the state anxiety level of children who stated that they frequently contact their friends via the Internet were higher than the other participating children. Although this result may seem a little confusing, it may be a result of these children's need for frequent meetings with friends because of their high anxiety.

In this study, close to half of the children reported that they never went out (43.4%) or occasionally went out to the yard only (53.1%). Sprang and Silman (2013) reported that isolation and quarantine measures taken during pandemics cause children to experience trauma. These researchers reported that posttraumatic stress developed in 30% of children and 25% of parents (Sprang & Silman, 2013) . In a recent study conducted with 1143 parents in Italy and Spain, it was determined that quarantine implementation significantly affected children's lives, and 85.7% of the parents perceived changes in their children's emotional state and behaviors during quarantine. Here, the most common symptoms in children were difficulty concentrating, boredom, irritability, restlessness, nervousness, feelings of loneliness, uneasiness and worry (Orgilés et al., 2020) . The results of a study conducted with 7143 university students showed that 0.9% of the participants experienced severe anxiety, 2.7% had moderate anxiety, and 21.3% had mild anxiety . Thus, the impact of quarantine on youth can be widespread and significant.

This study also has several limitations. First, data collection was completed by distributing questionnaires to children online. The results and conclusions may be influenced by the degree of understanding and cooperation of the respondents, especially the younger children who needed help of their parents. Second, as the study was | 5 conducted at a south-eastern Turkish province that was exercising a curfew, the results cannot be generalized to all children in the country.

It was determined in this study that the pandemic caused significant changes in children's routines and that many of these same children experienced moderate or high levels of anxiety. To minimize the psychological impact of the pandemic on children, it is recommended that governments and parents take institutional and individual steps, respectively. Parents need to support maintaining their children's pre-pandemic routines as much as possible. To minimize emotional problems during the pandemic, parents need to carefully monitor their children's emotional well-being and seek help when necessary.

Collaborative games with children and engaging in activities that promote physical activity can help reduce anxiety.

Due to the COVID-19 pandemic, curfews have been imposed in different countries around the world and at different times (Gostin & Wiley, 2020; Lasry et al., 2020; Oksanen et al., 2020) . Turkey is the only country worldwide to apply a unique age-stratified curfew; this first started for seniors older than 65 years and followed by the curfew order for children and youth younger than 20 years (Kanbur & Akgül, 2020) . After a circular was issued by Ministry of Interior and these must also be recognized. Primary healthcare providers and psychiatric nurses should increase attention to children's mood and intervene to protect and improve children's mental health during and after immediately the pandemic. Since the anxiety experienced by parents may also have an impact on children, studies that evaluate the stress level of the parents are necessary.

The psychological impact of the COVID-19 epidemic on college students in China

Returning Chinese school-aged children and adolescents to physical activity in the wake of COVID-19: Actions and precautions

Protecting the psychological health of children through effective communication about COVID-19. The Lancet Child & Adolescent Health

An investigation of mental health status of children and adolescents in china during the outbreak of COVID-19

Children and the pandemic: Anxiety, hopes and everyday life

Governmental public health powers during the COVID-19 pandemic: Stay-at-home orders, business closures, and travel restrictions

Clinical characteristics of coronavirus disease 2019 in China

The kids will be all right,' won't they? | The Hospitalist

Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants, and children

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet

Behavioral and emotional disorders in children during the COVID-19 epidemic

Quaranteenagers: A single country pandemic curfew targeting adolescents in Turkey

Timing of community mitigation and changes in reported COVID-19 and community mobility-Four

Mental health effects of school closures during COVID-19. The Lancet Child & Adolescent Health

Mental health considerations for children quarantined because of COVID-19. The Lancet Child and Adolescent Health

A singlecenter, retrospective study of COVID-19 features in children: A descriptive investigation

Regulation and trust: 3Month follow-up study on COVID-19 mortality in 25 European countries

Immediate psychological effects of the COVID-19 quarantine in youth from Italy and Spain

Çocuklar için Durumluk-Sürekli Kaygı Envanteri Uyarlama, Geçerlik ve Güvenirlik Çalışması

COVID-19-related school closings and risk of weight gain among children

Posttraumatic stress disorder in parents and youth after health-related disasters

Şehir Giriş/Çıkış Tebirleri ve Yaş Sınırlaması Genelgesi

Coronavirus: Impact on young people with mental health needs

Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China

A longitudinal study on the mental health of general population during the COVID-19 epidemic in China

Mart 21 Mitigate the effects of home confinement on children during the COVID-19 outbreak

The authors would like to thank all the children and their parents who participated in the study voluntarily.

The authors declare that there are no conflict of interests.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

http://orcid.org/0000-0003-1453-6028