The Consequences of COVID-19-Related Anxiety on Children’s Health: A Cross-Sectional Study

Background: The emergence of the COVID-19 pandemic has triggered a worldwide health catastrophe. Anxiety caused by COVID-19 has had a negative impact on people's physical and mental health. According to the ndings of the research, signicant emphasis has been devoted to measures linked to the identication of persons with coronavirus infection, but the identication of the affected individuals' mental health issues has been overlooked. Despite study data indicating an increase in fear and anxiety in patients with coronavirus and others, little research on COVID-19-related cardiac disease has been conducted so far. Methods: This cross-sectional study used a survey method with a chosen self-reported questionnaire for data collection from Mashhad residents. The research sample included 435 households with children aged 5 to 18. The data was analyzed using SPSS software version 25 and comprised two measures, (1) the Coronary Disease Anxiety Scale (CDAS) and (2) the Child Health Questionnaire (CHQ) developed by Landgraf and Abets. The ndings indicated that COVID-19-related anxiety has a detrimental inuence on children's health. According to the data, 19% of the children’s variance showed negative effects on health ( β= -0.625, Sig = 0.001, Adj.R2 = 0.193). Results: The ndings revealed a signicant difference in children's health mean scores related to forms of insurance coverage, parents' education level, housing status, and COVID-19-associated anxiety. Children's anxiety levels have increased, causing harm to their health and a reduction in their health status. Conclusion: The outcomes of the study will help health professionals and governments establish appropriate protective measures to address this worldwide health problem.

As previously stated, fear and anxiety about COVID-19 illness are now widespread [24]. Anxiety is a frequent unpleasant feeling felt by people during a disease outbreak [25]. Previous research has found that in the early phases of the coronavirus outbreak in China, more than half of respondents experienced signi cant psychological symptoms, with around one-third reporting moderate to severe anxiety [26][27][28].
Concerning the prevalence of anxiety in individuals, one of the primary issues that may be stated is the health condition of children, in such a manner that; the United Nations has encouraged all countries to prepare for the care and health of children, particularly during this time. The importance of this issue is such that worldwide strategies for the health of children and their mothers address four variables in decreasing child mortality and ve aspects in promoting newborn health [29,30]. It is worth noting that, because children's cognitive capacity is restricted in childhood, they learn the majority of their knowledge of the world around them with the assistance of their parents, and as they get older, their intellectual powers increase and they progressively become independent. In the meanwhile, parents are a valuable source of guidance and instruction [31]. One of the preventive factors against children's psychological and behavioral disorders that has a direct in uence on children's health is the interaction between parents and children [32,33].
According to the ndings of the research, signi cant emphasis has been devoted to measures linked to the identi cation of persons with coronavirus infection, but the identi cation of the a icted individuals' mental health issues has been ignored [34][35][36]. Despite study data indicating an increase in fear and anxiety in patients with coronavirus and others, little research on corona heart disease has been conducted to date [21]. Consequently, in 2021, this study investigated the link between corona anxiety and children's health in parents with children aged 5-18 years in Mashhad, a city in northern Iran.

Design
This cross-sectional research was conducted in the northern Iranian metropolis of Mashhad in 2021.

Population
Families with children aged 5 to 18 years were included in the statistical population. The SPSS Sample Power program was used to calculate the sample size.

Measures (anxiety)
The COVID-19 Anxiety Scale (CDAS) [37] and the Child Health Questionnaire (CHQ) Landgraf and Abets (1996) [38] were utilized in the current investigation. The COVID-19 Anxiety Scale, developed and validated in Iran, is used to assess anxiety induced by COVID19-related heart disease. This questionnaire consists of 18 items and two components. Items 1-9 evaluate psychological symptoms, whereas items 10-18 evaluate physical problems. The tool is evaluated using a four-point Likert scale (never, sometimes, most of the time, and always). The respondents' greatest and lowest scores on this questionnaire ranged from 0 to 54. A high level of anxiousness is indicated by a high score. The Cronbach's alpha technique determined the instrument's reliability for the rst factor (α = 0.879), the second factor (α = 0867), and the entire questionnaire (α = 0.919) [37]. The Landgraf and Abets Child Health Questionnaire was used to examining children's health. This questionnaire's basic form and 28 items had 13 subscales that investigated two aspects of physical health (including functional subscales or physical problems and limitations, general health, and physical pain) and psychological health (includes subscales of social, emotional-behavioral limitations, self-esteem, mental health, and behavior and family problems). This questionnaire is one of the most widely used scales related to health and quality of life for children and adolescents, assessing noticeable areas of child function and health based on parent reports, and it can be used for girls and boys of various ages, as well as parents with varying levels of education and working and marital situations [39]. Validity studies in Iran have shown that CHQ can discriminate between children with certain chronic illnesses and that it is associated with other health and quality of life scales. This questionnaire has 22 questions. The questions are scored on a 5-point Likert scale. The tool is intended to assess eight aspects of child mental health, child self-satisfaction, child mobility, child performance, parental worry, parental limits, child general health, and overall child health score. The ndings of this tool's factor analysis in the research of Golzar et al. [40] were reported twice, at 0.05 and 0.06, respectively, indicating that this instrument is well-suited for usage in Iran. It should be noted that the questions in this instrument are evaluated using a Likert scale, and the tool's validity has been investigated in internal and external studies [41,42].

Data Collection
The following assumptions are proposed for determining sample size in the current study: 1-The probability of the rst type error is a maximum of 5% (alpha value), 2-The probability of the second type error is a maximum of 20% (beta value), 3-The test power is 80%, 4-The 95% con dence level, and 5-the sample size is such that at least 15% of the correlation is detected. The sample size of 540 individuals was then established using the SPSS Sample Power program. The surveys were sent online to parents with children aged 5 to 18 years, and 435 completed questionnaires were used as the foundation for analysis.

Data analysis
For data analysis, the SPSS-22 program was used. The data was further analyzed using two independent sample t-tests, one-way analysis of variance, and simple linear regression.

Ethics approval and consent to participate
All procedures in studies involving human subjects were carried out in line with the institutional research committee's ethical standards, as well as the 1964 Helsinki Declaration and its subsequent modi cations or similar ethical standards. The study procedure was authorized by the Medical Ethics Committee at the University of Social Welfare and Rehabilitation Sciences in Tehran (IR.USWR.REC.1400.043). This study included individuals who provided informed consent. Before commencing the study, the authors acquired verbal informed consent from all participants, and all participants completed the informed written consent-form after being told about the purposes of the project.

Sociodemographic
According to the ndings, the mean age of children was 12.21 years, while the mean age of parents was 39.16 years. The respondents' minimum age was 23 years, and their maximum age was 65 years. The mean CHQ and CDAS score of children was 210 (48.2%) 87.1 ± 12.1, 12.2 ± 8.4 in the boy group and 225 (51.6%) 84.1 ± 12.8, 13.1 ± 9.2 in the girl group, and the t-test ndings indicated that there was a signi cant difference in the mean health score of children in the gender group of children (P < 0.05). Other ndings revealed that the greatest mean health score of children was connected to children with supplementary insurance (90.9 ± 4.1), and the lowest health score was related to uninsured children (81.6 ± 14.7). Furthermore, children with supplementary insurance had the lowest mean CDAS score (9 ± 5.5). The ANOVA test ndings also revealed a signi cant difference in the mean score of children's health based on the status of children's insurance (P < 0.05). The highest mean health score of children was associated with parents with a bachelor's degree (87.7 ± 10.6), while the lowest health score was associated with illiterate parents (80.5 ± 14.3). In addition, children with a Ph.D. had the lowest mean CDAS score (8.2 ± 5). The ANOVA test ndings also indicated a signi cant difference in the mean score of children's health based on parents' educational position (P < 0.05). The ndings on the mean anxiety score from the pandemic revealed that depending on the status of the type of housing, children living in leased housing had the highest mean anxiety score from the corona (15.3 ± 10.1) (P < 0.05). The ANOVA test results also revealed a signi cant difference in the mean score of children's health based on dwelling type (P < 0.05) ( Table 1).
The ndings of the regression test showed that that anxiety has an effect on children's health (β=-0.625, Sig.=0.001, Adj.R2 = 0.193). This variable accounted for 19% of the variation in children's health.
According to the data, the higher the degree of corona anxiety among youngsters in Mashhad, the worse their health (Table 2).

Discussion
The current study investigated the relationship between COVID-19-related anxiety and the health of children aged 5 to 18 in Mashhad, a city in northeastern Iran. According to the ndings of this study, COVID-19-related anxiety impacted children's health. Other studies have revealed that COVID-19 disease causes emotions of uncertainty, fear, and isolation, as well as sleep di culties, anorexia, depression, loneliness anxiety, post-traumatic stress disorder, and obsessive-compulsive disorder in children [43,44]. On the other hand, quarantine regulations and social isolation have resulted in a lack of physical exercise in them [45]. This separation has restricted children's opportunities to acquire social behaviors and, in some cases, behavioral and emotional problems [46]. Other research has suggested that providing appropriate information about COVID-19 illness might relieve children's emotions of fear, worry, and doubt, as well as teach them good coping strategies [47]. According to the ndings of the research, children's degree of awareness had a signi cant link with their anxiety, such that children who were more aware of this sickness experienced greater anxiety. Concerning the principles of crisis intervention, there is a need to appropriately increase awareness by addressing the idea of epidemic cessation. Increasing awareness through interventions such as social distance during the epidemic and obeying sanitary principles such as frequent handwashing with soap and water might help in this respect. Consequently, it is critical to pay attention to how children get the majority of their information, what methods should be used to improve awareness in children, and what variables, in addition to the degree of awareness, have in uenced their anxiety [48]. According to the ndings of a study conducted in the Netherlands, interaction with children by health care workers can decrease anxiety linked with the COVID-19 pandemic in children and its possible harmful effects [43]. Educating parents on how to control their negative emotions is also a crucial step in fostering and sustaining children's mental health in times of crisis. As a consequence, providing information about COVID-19 disease based on children's cognitive development, health attitudes, and age is essential [48,49]. Yoga, meditation, exercise, and mental activity can help reduce the anxiety produced by COVID-19, and in order to ght the pandemic, parents and children must work together to diminish the harmful consequences of COVID-19-related anxiety on children's health [50].
In our study, there was a substantial variation in the mean score of children's health based on the kind of insurance coverage. Other research has found that having access to social insurance has a substantial impact on the number of times youngsters visit the doctor [51]. Furthermore, expanding public insurance coverage reduced deprivation at the communal level [52] as well as the nancial burden on low-income households [53]. As previous studies have highlighted, this state can help to reduce poverty and inequality in society, as well as impact children's well-being. Children's well-being and health are critical for any society's future [53,54]. Today's children are our future generation, and their well-being today lays the groundwork for their health during adolescence. Access to health system services, such as health insurance coverage, is a social and economic right, and health planners must plan carefully to enhance justice and equity in this area.
According to the ndings of the current study, there is a strong relationship between parents' educational level and their children's health. Other studies have found that parental literacy has an impact on children's health and that it is important to engage in their development in order to enhance children's health [54][55][56]. Some studies have indicated that women's education levels have an in uence on children's health [57], and others have found that maternal and paternal education are equally important in lowering child mortality in Indonesia [56,58]. In developing countries, fathers generally have a greater level of education than mothers. Therefore education for fathers might be bene cial. Another way to describe the role of fathers' education is the low social position and empowerment of mothers, which has the ability to diminish mothers' in uence over child health decisions. Fathers may take a more active part in certain sorts of child health decisions, such as speci c measures like immunizations. Mothers, on the other hand, maybe more active in day-to-day decisions concerning public health and nutrition. The father's education has a stronger association with individual health habits, but the mother's education has a greater impact on long-term health indicators like height and weight [59,60]. Parents with a greater level of education and income, as well as children from higher-income households, are healthier because they have access to higher-quality health care, better nutrition, and better living conditions. This research has underlined the need for increasing parental education via investment.
The current investigation found a strong relationship between the mean score of housing status and cardiac anxiety. Hence, those who lived in leased homes were more anxious. This issue has caused several issues in society. Despite this, research has shown that the coronavirus does not discriminate based on personal residence and affects leased homes just as often as homeowners.
[61]. Perhaps the economic crisis caused by the COVID-19 pandemic, as well as issues like unemployment and a lack of nancial support for households, has increased anxiety among renters. According to the ndings of previous research, the cost of renting a property in Iran is high [24,62], which may increase anxiety in leased families indirectly.
The current research was conducted during the pandemic. Due to special circumstances in Iran, such as lockdown, it was not feasible to complete the surveys in person. For that purpose, the surveys were sent to parents over the internet. Another drawback of this study was the use of questionnaires, as there is a risk of bias in self-report instruments. Regarding the aforementioned constraints and the study's nal conclusions, it is proposed that in future studies, further research be performed to clarify the link between variables in other provinces and cities around the country to clarify the relationship between investigated variables. Various aspects related to children's health, such as parenting and self-care principles, as well as other degrees of anxiety in children should be examined.