Association between Diet History and Symptoms of individuals having recovered from COVID-19

DOI: https://doi.org/10.21203/rs.3.rs-1619437/v1

Abstract

Background:

Many studies show that people who eat a balanced diet have stronger immunity. The present work aimed to identify the effects of the diet history of COVID-19 patients having recovered from the disease on the occurrence and severity of symptoms.

Methods:

The study sample consisted of 346 individuals aged 20–65 years. Participants’ data and answers to an electronic questionnaire regarding their diet history and symptoms were collected. The study focused on four hard symptoms (fever, body pain, cough, and dyspnea) to investigate the relationship between these symptoms and the consumption of specific immunity foods.

Results:

Symptoms were reported by 88.1% of the participants eating none of the foods investigated, whereas 85.54% and 85.55% of the individuals with little or intensive food intake, respectively, experienced symptoms.

Conclusions:

Intake of specific functional foods might slightly reduce the occurrence of some symptoms.

Introduction

The coronavirus disease 2019 or COVID-19 is characterized by serious acute respiratory symptoms [1]. This disease originated at the end of 2019 in Wuhan, China [2, 3]. In March 2020, the World Health Organization (WHO) considered the COVID-19 outbreak a global pandemic [4]. Since 14 February 2020, when the first cases of COVID-19 infections were reported in Egypt, the Egyptian people have lived in a different reality [5, 6]. The first symptom usually experienced by COVID-19 patients is pain, particularly headaches, myalgia, or arthralgia. The pain appears 1.6 days after the onset of illness. The second set of symptoms is fever, followed by cough and diarrhea. Then, patients suffer from anosmia, which occurs days after the onset of infection. All symptoms persist for 10 ± 4.9 (mean ± standard deviation) days (range of 3–27 days), except for the fever, cough, and anosmia that last 5.5 ± 4.4 (range of 1–19 days), 7.7 ± 4.3 (range of 1–18 days), and 7.3 ± 5 (range of 1–19 days), respectively [7].

The nutritional status, which results from the diet history, can significantly impact the overall health and reduce the risk of developing infections [8]. Healthy nutritional habits help prevent non-communicable diseases, which are risk factors for developing COVID-19 [9]. Additionally, nutrition has been linked to systemic infectious diseases through its effects on the immune system [10]. Thus, malnutrition increases the host’s susceptibility to infectious diseases. These infections negatively affect the metabolism, worsening the nutritional state [11]. Moreover, getting used to a healthy lifestyle is important for reducing cholesterol levels and increasing antioxidant levels from fruits, vegetables, and monounsaturated fatty acids present in fish, nuts, and olive oil [12]. Moreover, the frequent consumption of healthy foods such as vegetables, fruits, and fish contributes to supplying the body with sufficient amounts of essential nutrients and antioxidants [13, 14]. In Damietta (Egypt), most COVID-19 patients have poor nutritional habits and present severe symptoms of fatigue. Additionally, most COVID-19 patients are overweight or obese, and these patients have more severe symptoms of fatigue [15]. Interestingly, the Mediterranean diet is one of the healthiest diets in the world and is associated with lower rates of mortality, obesity, type 2 diabetes mellitus, low-grade inflammation, cancer, Alzheimer’s disease, depression, and COVID-19 [12, 16].

Therefore, the current study aimed to determine the effects of the nutritional history of patients having recovered from COVID-19 on the occurrence and intensity of some of their symptoms.

Subjects and Methods

Study Design and Participants

This study took place in Egypt (Damietta Governorate). A random sample of 346 individuals who had recovered from COVID-19 was selected. The sample consisted of 212 women and 134 men aged 20 to 65 years, 131 from rural areas, and 213 from urban areas. The illness lasted 14 to 21 days for most people (52.3% subjects).

All participants consented to share their data by sending back the electronic questionnaire. Several specialized faculty members from the faculty of specific education at Damietta University verified the test’s validity. The two tests’ stability coefficient was calculated before using the data. The average time spent filling out the survey was 10 minutes.

The Study Collected

1) Personal information (gender, location, age, and illness duration)

2) Answers to a structured questionnaire on diet history.

Then, the relationship between the diet history, particularly consuming certain foods, and the degree of some symptoms was determined.

An electronic questionnaire (in the Arabic language) was built using the Google Form application [17, 18] and can be viewed at the following URL:

https://docs.google.com/forms/d/e/1FAIpQLSfNudaJ3Hpn1XonEFU-rJkq5zZnywYhDzoV9Y28rQ9NkmQ8LA/viewform?usp=sf_link

COVID-19 Cases

COVID-19 cases have been defined as symptomatic (with fever, cough, nasal congestion and runny nose, sore throat, dyspnea, loss of smell or taste, body pain, and diarrhea) or asymptomatic (defined as a positive PCR or antibody test without typical COVID-19 symptoms) [19].

Severity and Duration of COVID-19 Illness

Participants rated their COVID-19 symptoms from three options: asymptomatic, moderate symptoms, and severe symptoms. In addition, they had to indicate the number of days spent presenting COVID-19 symptoms [19].

Statistical Analysis

SPSS statistical software (version 11.5.1) was used to analyze the data collected using Pearson’s correlation coefficient (R) [20].

Results

Table (1) recapitulates the COVID-19 symptoms that were investigated, namely fever, body pain, cough, nasal congestion, runny nose, sore throat, diarrhea, dyspnea, and loss of smell or taste. Most participants reported having had a moderate fever, cough, nasal congestion, runny nose, sore throat, diarrhea, and dyspnea (52%, 63.6%, 59%, 53.8%, 49.1%, and 53.2%, respectively). Then, the rest of participants had severe body pain and smell or taste loss (67.6% and 48.6%, respectively).

Thus, most participants had moderate symptoms, some had severe symptoms, and a minority was asymptomatic.

Table 1: COVID-19 symptoms investigated

Symptoms

Non

Moderate

Severe

Fever

N

48

180

118

%

13.9

52

34.1

Body pain

N

4

108

234

%

1.2

31.2

67.6

Cough

N

74

220

52

%

21.4

63.6

15

Nasal congestion and runny nose

N

80

204

62

%

23.1

59

17.9

Sore throat

N

62

186

98

%

17.9

53.8

28.3

Diarrhea

N

140

170

36

%

40.5

49.1

10.4

dyspnea

N

70

184

92

%

20.2

53.2

26.6

Loss of smell or taste

N

52

126

168

%

15

36.4

48.6

N: Number of participants


Tables (2) to (6) present the relationship between COVID–19 symptoms (fever, body pain, cough, and dyspnea in tables (2), (3), (4), and (5), respectively) and intake of some foods (fruits or vegetables, yogurt, onions, and garlic). Each table was divided into three levels of food intake: 1) no intake, 2) little intake (weekly or monthly), and 3) intensive intake (more than once a week to daily).

Table (2) shows that participants experienced fever independently of their food intake. Data showed that among 166 recovered individuals who did not eat any of the investigated foods, 20 (12.5%) had been asymptomatic, whereas 146 (87.5%) had suffered from either moderate or severe fever. Among the 338 participants with little food intake (weekly or monthly), only 38 cases (11.24%) had no fever, whereas 300 (88.76%) had experienced moderate or severe fever. Finally, among the 877 subjects with intensive food intake (daily or more than once a week), 134 (15.26%) had had no fever, and 744 (84.74%) had suffered from moderate or severe fever.

These data indicate comparable fever occurrence rates (88% and 88.8%) in participants with no or little food uptake, whereas fever occurred less in subjects with intensive intake (84.7%). Additionally, the foods investigated here had different effects on the occurrence of fever. For example, fever was reported less (80%) by participants consuming no vegetables or fruits (no intake), whereas it occurred the most (92.9%) in subjects who did not eat yogurt. Participants with little intake (weekly or monthly) of yogurt, vegetables or fruits (87% and 87.5%, respectively) experienced fever less often. Fevers were more intense in subjects consuming only small amounts of onions and garlic (91.9% and 89.4%, respectively). Finally, 86.3%, 84.7%, 84.2%, and 83.3%) of participants with an intensive intake (daily or more than once a week) of fruits or vegetables, yogurt, garlic, and onion, respectively, had a fever.

There was a significant correlation between fever occurrence, onion, and total food consumption (Pearson’s correlation coefficient R = 0.141 and 0.135, respectively, p < 0.01).

Table (2): Relationship between the consumption of specific foods and the occurrence of fever

Level of intake

Foods

Symptom rate

Fruits or vegetables

Yogurt

Onions

Garlic

Total symptoms

N

%

N

%

N

%

N

%

N

%

No intake

Asymptomatic

4

20

2

7.1

6

10.7

8

12.9

20

12

Symptoms

Moderate

8

40

14

50

26

46.4

32

51.6

80

48.2

Severe

8

40

12

42.9

24

42.9

22

35.5

66

39.8

Total

16

80

26

92.9

50

89.3

54

87.1

146

88

Total

20

100

28

100

56

100

62

100

166

100

Little intake (monthly or weekly)

Asymptomatic

8

12.5

14

13

6

8.1

10

10.6

38

11.2

Symptoms

Moderate

34

53.1

58

53.7

38

51.4

48

51.1

178

52.3

Severe

22

34.4

36

33.3

30

40.5

36

38.3

124

36.5

Total

56

87.5

94

87

68

91.9

84

89.4

302

88.8

Total

64

100

108

100

74

100

94

100

340

100

Intensive intake (daily or more than once a week)

Asymptomatic

36

13.7

32

15.3

36

16.7

30

15.8

134

15.3

Symptoms

Moderate

138

52.7

108

51.4

116

53.7

100

52.6

462

52.6

Severe

88

33.6

70

33.3

64

29.6

60

31.6

282

32.1

Total

226

86.3

178

84.7

180

83.3

160

84.2

744

84.7

Total

262

100

210

100

216

100

190

100

878

100

Total

346

346

346

346

1384

R

0.063

0.075

0.141**

−0.068

0.135**

N: Number of participants
R: Pearson’s correlation coefficient
**: P-value of correlation was significant (p < 0.01), 2-tailed test.

 

Data in Table (3) showed that 100% of participants not eating any of the investigated foods (no intake) had moderate or severe body pain symptoms. Moderate or severe body pain was experienced by 98.8% of the participants with little food intake (weekly or monthly) and 98.6% of those with an intensive intake (daily or more than once a week) of the foods. In view of the fact that the proportion of patients suffering from body pain decreased, these foods and their bioactive compounds may have affected the body’s resistance to pain.

Additionally, data in Table (3) revealed that 100% of participants who had experienced body pain were eating few fruits or vegetables and onions (weekly or monthly). In contrast, a slight decrease in the proportion of participants who had suffered from body pain occurred with the intensive consumption of yogurt, garlic, fruits or vegetables, and onions (99%, 98.9%, 98.5%, and 98.1%, respectively).

Table (3): Relationship between the consumption of specific foods and the occurrence of body pain

Level of intake

foods

Symptom rate

Fruits or vegetables

Yogurt

Onions

Garlic

Total symptoms

N

%

N

%

N

%

N

%

N

%

No intake

Asymptomatic

0

0

0

0

0

0

0

0

0

0

Symptoms

Moderate

8

40

8

28.6

14

25

18

29

48

28.9

Severe

12

60

20

71.4

42

75

44

71

118

71.1

Total

20

100

28

100

56

100

62

100

166

100

Total

20

100

28

100

56

100

62

100

166

100

Little intake (monthly or weekly)

Asymptomatic

0

0

2

1.9

0

0

2

2.1

4

1.2

Symptoms

Moderate

16

25

46

42.6

32

43.2

32

34.1

126

37

Severe

48

75

60

55.5

42

56.8

60

63.8

210

61.8

Total

64

100

106

98.1

74

100

92

97.9

336

98.8

Total

64

100

108

100

74

100

94

100

340

100

Intensive intake (daily or more than time weekly)

Asymptomatic

4

1.5

2

1

4

1.9

2

1.1

12

1.4

Symptoms

Moderate

84

32.1

54

25.7

62

28.7

58

30.5

258

29.4

Severe

174

66.4

154

73.3

150

69.4

130

68.4

608

69.2

Total

258

98.5

208

99

212

98.1

188

98.9

866

98.6

Total

262

100

210

100

216

100

190

100

878

100

Total

346

346

346

346

1384

R

−0.057

0.024

0.069

−0.018

0.037

N: Number of participants
R: Pearson’s correlation coefficient

 

Data in table (4) showed Cough symptoms occurred in participants who did or did not eat the investigated foods. According to the findings, 166 recovered individuals who did not consume any food had experienced either a moderate or severe cough. Among the 340 participants having little food intake (weekly or monthly), 258 (75.9%) had suffered from moderate or severe cough symptoms. Finally, among the 878 individuals with intensive food intake (daily or more than once a week), 684 (77.9%) had moderate or severe cough symptoms.

These data revealed a similar cough occurrence in individuals with little or intensive dietary intake (75.9% and 77.9%, respectively). This rate increased in participants eating none of the investigated foods (87.9%). Additionally, the foods tested in this study had different effects on cough occurrence. Participants eating no yogurt reported fewer cough symptoms (78.6%) than those who consumed no garlic, onions, or fruits or vegetables (90.3%, 90%, or 89.3%, respectively). Few individuals appeared to have cough symptoms (68.8%) with little intake (weekly or monthly) of fruits or vegetables, compared to those rarely eating yogurt or garlic (75.9% or 76.6%, respectively). Participants with little onion intake reported experiencing cough symptoms (81.1%). Finally, fewer subjects who often (daily or more than once a week) ate onions or garlic developed cough symptoms (75% and 75.8%, respectively). In contrast, the cough was most experienced by individuals who often had yogurt, fruits or vegetables (80% or 80.2%, respectively). There was a significant correlation between garlic consumption and cough severity (R = 0.116, p 0.05).

Table (4): Relationship between the consumption of specific foods and the occurrence of cough

Level of intake

Foods

Symptom rate

Fruits or vegetables

Yogurt

Onions

Garlic

Total symptoms

N

%

N

%

N

%

N

%

N

%

No intake

Asymptomatic

2

10

6

21.4

6

10.7

6

9.7

20

12.1

Symptoms

Moderate

15

75

18

64.3

34

60.7

34

54.8

101

60.8

Severe

3

15

4

14.3

16

28.6

22

35.5

45

27.1

Total

18

90

22

78.6

50

89.3

56

90.3

146

87.9

Total

20

100

28

100

56

100

62

100

166

100

Little intake (monthly or weekly)

Asymptomatic

20

31.2

26

24.1

14

18.9

22

23.4

82

24.1

Symptoms

Moderate

38

59.4

62

57.4

34

45.9

52

55.3

186

54.7

Severe

6

9.4

20

18.5

26

35.2

20

21.3

72

21.2

Total

44

68.8

82

75.9

60

81.1

72

76.6

258

75.9

Total

64

100

108

100

74

100

94

100

340

100

Intensive intake (daily or more than time weekly)

Asymptomatic

52

19.8

42

20

54

25

46

24.2

194

22.1

Symptoms

Moderate

167

63.7

98

46.7

110

50.9

92

48.4

467

53.2

Severe

43

16.4

70

33.3

52

24.1

52

27.4

217

24.7

Total

210

80.2

168

80

162

75

144

75.8

684

77.9

Total

262

100

210

100

216

100

190

100

878

100

Total

346

346

346

346

1384

R

0.022

−0.086

0.014

−0.116*

−0.002

N: Number of participants
R: Pearson’s correlation coefficient
*: P-value of correlation was significant (p < 0.05), 2-tailed test.

 

Data in Table (5) presented the link between the consumption of some foods and the development of dyspnea. Data revealed that 36 out of 166 recovering participants who did not eat the foods did not develop symptoms (21.7%), whereas 130 (78.3%) had suffered from either moderate or severe dyspnea. Among the 340 who had a small intake (weekly or monthly) of foods, only 74 (21.8%) had not had dyspnea, whereas 266 (78.2%) had suffered from either moderate or severe dyspnea. Finally, among the 878 individuals consuming the foods regularly (daily or more than once a week), 170 (19.4%) had not experienced dyspnea, whereas 708 cases (80.6%) developed moderate or severe dyspnea. The data also showed that many individuals had developed dyspnea regardless of their general food consumption (78.3%, 78.2%, and 80.6%, for no, little, and intensive uptake, respectively). Among the participants having no intake of the foods, dyspnea symptoms were less observed in those who did not eat fruits or vegetables (70%), followed by those who did not eat garlic (77.4%), yogurt (78.6%), or onions (82.2%).

Additionally, fewer individuals with a low intake (weekly or monthly) of yogurt reported dyspnea symptoms (74.1%) than those eating little fruit or vegetables, garlic, or onions (78.1%, 80.9%, or 81.1%, respectively). Finally, participants eating regularly (daily or more than once a week) yogurt experienced dyspnea symptoms more often (82.9%) than those eating high levels of onions, garlic, or fruits or vegetables (78.7%, 80.9%, or 80.9%, respectively).

There was a significant correlation between total food consumption and the development of dyspnea (R = 0.062, p < 0.05).

Table (5): Relationship between the consumption of specific foods and the occurrence of dyspnea

Level of intake

Foods

Symptom rate

Symptoms rate

Fruits or vegetables

Yogurt

Onions

Garlic

Total symptoms

N

%

N

%

N

%

N

%

N

%

No intake

Asymptomatic

6

30

6

21.4

10

17.8

14

22.6

36

21.7

Symptoms

Moderate

8

40

18

64.3

26

46.5

34

54.8

86

51.8

Severe

6

30

4

14.3

20

35.7

14

22.6

44

26.5

Total

14

70

22

78.6

46

82.2

48

77.4

130

78.3

Total

20

100

28

100

56

100

62

100

166

100

Little intake (monthly or weekly)

Asymptomatic

14

21.9

28

25.9

14

18.9

18

19.1

74

21.8

Symptoms

Moderate

28

43.8

52

48.2

36

48.6

48

51.1

164

48.2

Severe

22

34.3

28

25.9

24

32.5

28

29.8

102

30

Total

50

78.1

80

74.1

60

81.1

76

80.9

266

78.2

Total

64

100

108

100

74

100

94

100

340

100

Intensive intake (daily or more than time weekly)

Asymptomatic

50

19.1

36

17.1

46

21.3

38

20

170

19.4

Symptoms

Moderate

148

56.5

114

54.3

122

56.5

102

53.7

486

55.4

Severe

64

24.4

60

28.6

48

22.2

50

26.3

222

25.2

Total

212

80.9

174

82.9

170

78.7

152

80

708

80.6

Total

262

100

210

100

216

100

190

100

878

100

Total

346

346

346

346

1384

R

0.063

−0.083

0.091

0.018

0.062*

N: Number of participants
R: Pearson’s correlation coefficient
*: P-value of correlation was significant (p < 0.05), 2-tailed test.

 

Table (6) summarizes the data from Tables (2), (3), (4), and (5) regarding the link between the food consumption history of individuals having recovered from COVID-19 and the rate of specific symptoms. The proportions of individuals who consumed a specific food, never (no intake), sometimes (little intake), or regularly (intensive intake) and developed a specific symptom were calculated. Moreover, the average proportion of participants developing symptoms according to their average intake of specific foods and the average proportion of individuals developing a specific symptom according to their global food consumption level were calculated. The data showed that symptoms were present in 88.1% of participants consuming none of the listed foods, 85.54% of those consuming these foods sometimes, and 85.55% of those eating these foods regularly.

This data draws attention to the fact that the food consumption history of recovered people might have increased their resistance to some symptoms, as fewer participants with little or intensive food intake presented symptoms than those who did not consume any of the foods.

Table (6): Relationship between the consumption of all investigated foods and the proportion of participants having symptoms.

level of intake

Foods

Kind of symptoms

Fruits or vegetables

Yogurt

Onions

Garlic

Average

%

%

%

%

%

No intake

fever

80

92.9

89.3

87.1

87.3

Body pain

100

100

100

100

100

Cough

90

78.6

89.3

90.3

87.1

Dyspnea

70

78.6

82.2

77.4

77.1

Average

85

87.5

90.2

88.7

87.9

Little intake (monthly or weekly)

fever

87.5

87

91.9

89.4

89

Body pain

100

98.1

100

97.9

99

Cough

68.8

75.9

81.1

76.6

75.6

Dyspnea

78.1

74.1

81.1

80.9

78.6

Average

83.6

83.8

88.5

86.2

85.6

Intensive intake (daily or more than time weekly)

fever

86.3

84.7

83.3

84.2

84.6

Body pain

98.5

99

98.1

98.9

98.6

Cough

80.2

80

75

75.8

77.8

Dyspnea

80.9

82.9

78.7

80

80.6

Average

86.3

86.7

83.8

84.7

85.4

Discussion

The authors think that this study is the first to link COVID-19 symptoms with consumption levels of some foods by recovered individuals from the disease. Then choose three food intake levels: no intake, little intake (weekly or monthly), and intensive intake (daily or more than once a week) and Four food types that positively affect the immune system were chosen. Indeed, fruits or vegetables provide high amounts of vitamins and minerals that are important for the immune system [21]. Additionally, a lower COVID-19 infection rate in individuals drinking yogurt daily than that of people not drinking yogurt has been reported [22]. Yogurt, a fermented dairy product, exhibits interesting properties related to the presence of bioactive peptides and probiotics that might play a beneficial role in COVID-19 presentation and outcome [23]. Kumar et al. (2015) indicated that onions possess immune-stimulatory activities toward murine lymphocytes [24]. Hirayama et al. (2019) also suggested that the intake of low or high doses of onion green leaf extract might positively regulate immune competence [25]. Garlic essential oil is also a valuable natural antiviral agent that contributes to preventing the invasion of the human body by a coronavirus [26]. Finally, the immune system is highly affected by malnutrition, which leads to decreased immune responses and a consequent augmented risk of infection and disease severity [27].

On the other hand, participants reported suffering from different symptoms, namely fever, body pain, cough, nasal congestion, runny nose, sore throat, diarrhea, dyspnea, and loss of smell or taste. However, the study found that four symptoms, i.e., fever, body pain, cough, and dyspnea, were more often experienced and were linked with the participants’ history of immune food consumption. These findings were similar to those reported by (Carfì et al. 2020) [28], who found that, after the onset of the first COVID-19 symptom, only 18 (12.6%) participants were completely free of any COVID-19 symptom, whereas 32% had 1 or 2 symptoms and 55% had 3 or more. A worse quality of life was observed among 44.1% of the patients. The data also shows that a high proportion of individuals reported myalgia (53.1%), dyspnea (43.4%), and joint pain (27.3%). In this respect, (Çalıca et al., 2020) reported that out of 297 patients, 143 had positive symptoms, and 154 had negative symptoms [29]. The most common symptoms in the positive group were cough (56.6%), weakness (56.6%), taste disorder (35.7%), myalgia (34.3%), and fever (33.6%), whereas in the negative group they were cough (63%), weakness (45.5%), dyspnea (29.9%), headache (27.3%), and fever (24.7%).

The present study compared the occurrence of symptoms according to the general and specific consumption of foods. Although there was no impact of food consumption on symptoms in general, the consumption of specific foods in given amounts affected the occurrence of some symptoms. The most notable difference was body pain, experienced by 100% of the participants who had not eaten any of the foods, whereas it was less present in individuals with low or high food intake. Moreover, as shown in Table (6), fewer symptoms were experienced by participants consuming the investigated foods sometimes (little intake) or regularly (intensive intake) compared with the group having no intake of these foods. These data contradict those of a previous study (Kim et al., 2021), indicating that no association was observed between diets and the odds of COVID-19-like illness or duration of symptoms [19].

Conclusions

The present study suggests that although there was no impact of food consumption on symptoms in general, the consumption of some foods i.e., (Fruits or vegetables, Yogurt, Onions and Garlic) affected the occurrence of some symptoms. The most notable difference was body pain.

Recommendation

The authors suggested to conduct more research by adding more foods related to COVID-19 symptoms especially for children and adolescent. Also, Governments should provide more information related immunity foods content in information, education and communication on pandemic targeted to the communities. Furthermore, civil society organizations should be special attention to assist social including immunity foods vulnerable groups in the family.

The Strengths And Limitations Of The Study Are

The strength of the study’s findings lies in the fact that the relationship between different consumption levels of specific foods by people having recovered from COVID-19 and the symptoms experienced by these individuals was investigated.

The limitation of the study was insufficient participants.

Declarations

Acknowledgements

We would like to thank all the doctors and nurses at the Isolation Hospital in Damietta, especially nurse Aya Al-Baghdadi.

Also, great thanks to "Research Square" to publish research as preprint in https://www.researchsquare.com/article/rs-1422489/v1

Funding

Transformative Agreement plus fully OA agreement, starting 01 January 2022 for Egyptian institution. This agreement will cover all the public, private and national universities, as well as the research centres related to the ministry of higher education and scientific research and all other governmental ministries in Egypt.

Authors' contributions - provide individual author contribution

OS prepared and wrote the manuscript. TS critically revised the manuscript for important intellectual content. All authors participated in the interpretation of the results and approved the final manuscript as submitted.

Ethics approval and consent to participate

The study was approved by the Ethics faculty members from the faculty of specific education at Damietta University. Informed written consent was obtained from each participant prior to participation, all participants consented to share their data by sending back the electronic questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

An electronic questionnaire (in the Arabic language) was built using the Google Form application

https://docs.google.com/forms/d/e/1FAIpQLSfNudaJ3Hpn1XonEFU-rJkq5zZnywYhDzoV9Y28rQ9NkmQ8LA/viewform?usp=sf_link

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