Using public playgrounds during COVID-19 pandemic: A Survey of Parental Knowledge, Attitudes, and Beliefs

Background: The possibility of COVID-19 transmission by environmental surfaces such as playground equipment has been previously suggested. The objective of this study was to investigate how the parents' Knowledge and beliefs regarding using public playgrounds contribute to asymptomatic community transmission of the virus. Methods: An online survey questionnaire was designed through SurveyMonkey (Palo Alto, California, USA), including 18 closed-ended and one open-ended question. Albertans having at least one non-school-aged child were invited to participate via a link placed on social media platforms. The initial survey was sent out in December 2020, and the survey period continued for 3 weeks. The survey results were summarized, graphed, and reported using SurveyMonkey. Results: A total of 162 anonymous responses were included in this study. Overall, the dimensions evaluated have demonstrated remarkable levels of compliance with the current public health measures among parents (Average score 6.1/9.0 (68%)). However, most respondents believed a more stringent health measure is needed to improve public playground safety during this pandemic, such as regular cleaning and sanitizing the equipment, capacity restrictions, sanitizer available at playgrounds, etc. While the majority of respondents were aware of the possibility of COVID-19 transmission through public playgrounds, there were some indications of inappropriate use of playgrounds; a few parents used playgrounds even after the child was diagnosed with Covid-19 infection or identied as a close contact of someone who is conrmed as having COVID-19 by a health care provider. Conclusions: Our study highlights the current lack of screening and risk assessments of public playgrounds that may contribute to an increase in a variety of pathogens, including COVID-19, that cause a range of health outcomes.


Introduction
Coronavirus Disease 2019 (COVID-19) has expanded as a global pandemic since December 2019 (1). In Canada, as of November 7, 2020, over 9 million tests have been performed, with over 260,000 tests resulting in positive(2). This disease has resulted in over 10,000 deaths in Canada (2). At the time of conducting this study, Alberta had the 7,736, second-highest number of active COVID-19 cases per capita in all provinces after Manitoba. Of which, over 1100 cases have been identi ed among children under six years old in Alberta (3).
Few epidemiological studies so far have focused on COVID-19 in children, mainly because they are supposed to have a signi cantly milder clinical symptom (4). However, a novel post COVID-19 hyperin ammatory syndrome has been reported in children that is potentially lethal, and long-term outcomes from this condition are currently unknown (4)(5)(6). In addition, evidence shows that children may play an important role in asymptomatic community transmission of the virus (7). This is important because evidence shows that of the 3,768 new cases reported in Alberta between October 27 and November 2, the source of infection could not be identi ed in 2,548 (67 %) cases (8).
Furthermore, children have been experiencing a high burden of indirect physical, social, and mental health effects due to reduced non-urgent care or general pandemic control measures (8). Therefore, the child health, while assessing the current outbreak, should not be neglected, and steps should be taken to mitigate the damage, especially now that the rise of the new variant, subsequently designated as delta, seems to have a higher transmission rate among children compared to previously identi ed variations (7). Important roles of public playgrounds in the transmission of non-COVID diseases in non-school-aged children have been reported previously (9,10), leading to the policy of preschool closure and disinfection of toys, and surfaces for outbreak control. So far, only one study has investigated playgrounds as a potential source of COVID-19 spread and reported that 4.6% of collected environmental samples tested positive for COVID-19. However, several studies have shown the Coronavirus can remain viable on metal, glass, and plastic for as long as nine days, and can even remain for up to 28 days in low temperatures unless they are properly disinfected (7)(8)(9). Given that the playground equipment is not currently being cleaned and sanitized regularly, there is a need for risk assessment. In addition, more studies are needed to clarify whether the recovery of viral RNA on outdoor surfaces also indicates the possibility of acquiring the virus and to monitor transmission dynamics in children by observing them and their parents or guardians. Therefore, in this study, we investigated how the parents' Knowledge and beliefs regarding using public playgrounds contribute to asymptomatic community transmission of the virus.

Study design and population
An online survey questionnaire was designed through SurveyMonkey (Palo Alto, California, USA) to assess whether parents comply with COVID-19 rules using playgrounds, the risk of COVID transmission from playgrounds, and to obtain parents' perspective of the current COVID guidance for using playgrounds among Albertans having at least one non-school-aged child. In total, 19 questions, 18 closed ended and one open ended question, were included in this survey.
Volunteers were invited to participate via a link placed on social media platforms, including Facebook, Twitter, Instagram, and LinkedIn. In addition to an Ad on Facebook, a passive recruitment, which involves distributing recruitment materials (ads, posters, and SurveyMonkey link) was used to attract potential participants to contact the research team for more information and consideration of enrollment. The social media platforms gave us the option to target users by speci c locations (i.e., Alberta) or demographic (e.g., adults, parents). Participation in this study was voluntary and anonymous, and no nancial compensation was offered to the participants.
The initial survey was sent out in December 2020, and survey period continued for 3 weeks.

Statistical consideration
Survey results were summarized, graphed, and reported using SurveyMonkey and STATA software. Quantitative variables were expressed as mean ± standard deviation (SD), for normally distributed data, or median (interquartile range (IQR)), for non-normally distributed data, respectively. Categorical data were expressed as numbers (percentages). For sensitive data, a statistic was suppressed if the number of actual records used in the calculation (not rounded or weighted) was less than 10, in accordance with the Statistics Canada guidelines (11,12).

Characteristics of respondents and their children
A total of 162 anonymous responses were included in this study. Characteristics of participants are shown in Table 1, panels A and B. The mean age of the guardians was 35.8 years, 134 (82.7%) were females (mother or other female guardians), 27 (16.7%) were males (father or other female guardians), and 1 (0.6%) was unknown. In addition, the majority of the guardians, 110 (67.9%), had a post-secondary degree, and had only one child 80 (49.4%).
The mean age of the children was 3.47 years, 79 (48.8%) were females, 82 (50.6%) were males, and 1 (0.6%) was unknown. The most common type of childcare programs used by guardians during the pandemic were preschool programs 31 (19.1%), and full-time or part-time daycare 29 (18%), respectively. However, the majority of the guardians, 59 (36.4%), did not used any types of childcare programs during the pandemic (Table 1, panel B).
The majority of children, 99.4% (161), never diagnosed with COVID-19 (The data on positive test result suppressed due to low cell count). Moreover, the number of the children that have been identi ed as a close contact of someone who is con rmed as having COVID-19 by a health care provider was low (data suppressed due to low cell count), while the of them never had a similar experience. In addition, the majority of them, 123 (75.9%), had not been directed by a health care provider to isolate ( Respondents' knowledge, and practices towards using indoor and outdoor playgrounds During the pandemic, the majority of guardians, 73 (45.1%), indicated that they used the public outdoor playground for their children a few times a week, and 15 (9.3%) did not used it at all. Surprisingly, there were some indications of using public outdoor playgrounds even after knowing the children was diagnosed with a COVID-19 infection or was close contact with someone who is con rmed as having COVID-19 (data suppressed due to low cell count) ( Table 2, panel A).
Regarding public indoor playground, 88.3% (n = 143) of the children did not use the playground during pandemic. Of these, only few of them used the playground after being close contact of someone who is con rmed as having COVID-19 (data suppressed due to low cell count). As shown in Supplementary  Table 1, most of the participants used outdoor, or indoor playgrounds located in NW, Calgary.
Interestingly, 48 participants indicated that they did not use public playgrounds even when they were not closed by a public health order. Among these, the main reported reason for not using public playgrounds was the COVID-19 pandemic 38 (79.2%).
The respondents were further asked in more detail about their compliance with health guidelines when using playgrounds. Collected data showed that the participants brought following equipment to playground as below: Hand sanitizer, wipes, water, and paper towels: 67.9% (n = 110), personal toys and sports equipment: 17.3% (n = 28), drinking water: 73.5% (n = 119), hats, sunscreen, or clothing for sun protection: 72.8% (n = 118), ABTraceTogether App installed on a cell phone: 11.7% (n = 19) ( (78.4%) didn't share toys, bikes or food with people outside of their household, 43 (26.5%) kept their pets away from others and didn't pet other people's animal as well, 136 (84%) used to wash hands often, especially before and after touching play equipment or shared areas, before and after eating or drinking, and nally 139 (85.8%) used a Health Canada approved hand sanitizer if soap and water weren't available, also, if hands were visibly dirty, rst used wet wipes or water to clean hands, then dried them with paper towels and applied the hand sanitizer (Table 3, panel B and Supplementary Fig. 2).
Respondents' perspective of the current COVID guidance for using playgrounds.
Given rate of the participants toward the current public health measures to minimize the spread of COVID-19 through public playgrounds has been summarized in Table 4, Panel A. The mean score was 4.8, and the standard deviation was assessed as 2.82 (Table 4, panel A). Also, suggestions of the participants to improve the public playground safety during this pandemic have been included in Table 4, panel B.

Discussion
To our knowledge, this is the rst study investigating how the parents' Knowledge and beliefs regarding using public playgrounds contribute to asymptomatic community transmission of the virus. In addition, this study describes the most important barriers to guideline implementation identi ed among parents.
Overall, the dimensions evaluated have demonstrated remarkable levels of appreciation for the current public health measures among parents. However, most respondents believed a more stringent health measure is needed to improve public playground safety during this pandemic.
While the majority of respondents were aware of the possibility of COVID-19 transmission through public playgrounds, there were some indications of inappropriate use of playgrounds; a few parents used playgrounds even after the child was diagnosed with Covid-19 infection or identi ed as a close contact of someone who is con rmed as having COVID-19 by a health care provider. In addition, only a small proportion of participants believed they should keep their pets away from others and do not pet other people's animals. In addition, ABTraceTogether, a mobile contact tracing app, had a low uptake among participants, and only a small proportion of participants had it installed on a cell phone when they used a public playground.
Although going to a public playground has been considered low risk for exposure to COVID-19, a higher frequency of contact with high-touch surfaces (e.g., playground equipment) is presumed to be associated with a higher risk of COVID infection (13)(14)(15). In addition, physical distancing is usually di cult to maintain at playgrounds. Although governments have provided guidance outlining public health and infection prevention and control measures speci c to this setting (16), there is still room for improvement.
In addition, certain barriers exist that prevent the implementation of public health measures.
A recent study by Kozer et al (17), assessed the presence of SARS-CoV-2 in environmental samples collected at public playgrounds, and reported that 4.6% of collected samples from playground equipment tested positive for COVID-19. However, the authors indicated that it is unclear whether the recovery of viral RNA on outdoor surfaces also indicates the possibility of acquiring the virus. Considering there is very little information about the role of public playgrounds in COVID transmission in the available literature, more caution is needed for parents when using public playgrounds.
Our paper emphasizes an urgent need for effective interventions to increase adherence to public health.
Although vaccinations process is being speed up in Alberta and rest of the word, the race against coronavirus variants in the coming months still depends on the public's ability to follow public health rules for the following main reasons: rst, the vaccines do not provide 100% protection; second, those who have been vaccinated can be asymptomatic spreaders, and nally, we still need to protect those with compromised immune systems and those who cannot be vaccinated, and children younger than 12 years who use playground often are among this group(18-21).
Our study results suggest that to improve the public playground safety both during pre-and post-Covid-19 pandemic, the followings measures could be added to the current health guidelines: 1) cleaning and sanitizing the equipment regularly, 2) capacity restrictions, 3) having sanitizer available at playgrounds, 4) having a clearer posted guideline.
A signi cant strength of the study is that it provides a baseline which will allow future research to assess the risk of COVID and other pathogen transmission through public playgrounds. However, our study has several limitations. Firstly, the use of a convenience sample (those who volunteer to do the survey) may limit the generalizability of the results, as those who agree to complete the survey may be different than those who do not. Second, the self-reporting nature of the questionnaire; Parents/guardians may provide answers re ecting how they wish to be perceived versus answers that represent the true nature of the situation. Third, this study provides the data from the second wave of the pandemic, and experiences are likely to change over time. Fourth, our study was not designed to assess risk of COVID-19 transmission by collecting samples from equipment. Finally, due to small sample size we were unable to explore the differences in responses according to characteristics of the child's parents or guardians.

Conclusion
Our results contribute to understanding of the risk of COVID transmission from playgrounds and how are parents' Knowledge and beliefs regarding using public playgrounds contribute to asymptomatic community transmission of the virus. In addition, our results highlighted the current lack of screening and risk assessments of public playgrounds that may contribute to an increase in a variety of pathogens that cause a range of health outcomes.

Declarations
Author Contributions: Dr. Taghizadeh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design (Taghizadeh); Acquisition of the data (Taghizadeh); Analysis and interpretation of the data (all authors); Drafting of the manuscript (Taghizadeh); Critical revision of the manuscript for important intellectual content (all authors). All authors approve nal version of the manuscript.
Funding Statement: This study was supported by STATCure Consulting Services Inc.
Availability of data and material: The data that support the ndings of this study are available from STATCure Consulting Services Inc, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Health Research Ethics Board of Alberta (HREBA).

Code availability
Code from Stata is available upon request.
Ethics approval: The study was approved by the Health Research Ethics Board of Alberta (HREBA) (protocol HREBA.CHC-20-0066).
Consent to participate: Participants signed an online consent form.
Consent for publication: The authors agree to the publication.
Con ict of interest: The researchers in this study received nancial payment from the STATCure Inc. to cover the cost of conducting this study. The researcher at this centre did not receive any direct bene t for conducting this study.

20.
Five reasons why COVID herd immunity is probably impossible. Available at:https://www.nature.com/articles/d41586-021-00728-2.     If you can't wash with soap and water, use a Health Canada approved hand sanitizer (read the label as some are not approved for children). If hands are visibly dirty, rst use wet wipes or water to clean hands, then dry them with paper towels and apply the hand sanitizer.  Have sanitizer available at playgrounds.

5
Hand sanitizer made available at all playgrounds. 6 Unfortunately, I have not allowed my child on playground, nor would I if he was older, due to the pandemic. You can't really reason with young children so safety measures including avoiding touch eyes, nose mouth etc and sanitizing cannot be guaranteed by a child. My child has not been to any public places due to the pandemic, except for the regular pediatrician's follow up. I have created my own play backyard for him. We follow hand hygiene protocols and I know what he is touching in my house and backyard has been thoroughly cleaned.

7
It is tough because all of the age groups mix in public playgrounds. At daycare -each group has their own segregated playground 8 I think using at your own risk and encouraging everyone to sanitize hands. 9 No-I believe they are quite safe and will be very disappointed if measures are put in place to shut them down again.

10
None. It is my understanding that outdoor public space transmission is low and therefore as long as my child is wearing a mask, socially distancing themselves from individuals outside of their household/cohort and washing their hands when they are removing their mask, they can use outdoor public playgrounds safely.

11
I will not go till it is safe to do so.

12
What public health measures? You guys don't enforce anything, playground or not. You wanna prevent spread? Close malls and crack down on other retail.

13
Enforce maximum capacity of outdoor gatherings at play grounds by the amount of space provided. 1 parent is most likely bringing 1-3 children to the park so saying 5 adults on the grounds as a maximum would be helpful. Outdoor playgrounds are relatively safe and necessary to maintain our sanity with our high-energy toddler. Speci c guidance/signage on outdoor masking would be welcome and valuable. Transmission among young children now seems much more likely than it did based on earlier research in the spring, but I donâ€™t believe many parents have adjusted their familyâ€™s behaviours â€" ie. Some people let their kids get too close to others.

27
Playgrounds (outdoors) are extremely low risk and should never have been closed or restricted in anyway whatsoever.

28
Unfortunately, many do not follow the recommendations even when the playgrounds were shut down. I think actual coverage of people suffering with COVID will be the only thing to educate people better. They do not believe it until they see for themselves and that makes it dangerous for the rest of us.

49
We haven't been to the park since the summer, but with all of the unknowns and poor government communication we instead added to our own playground for the kids. Including adding in a heated pool, swings, and hammock. Public Playgrounds should also be closed when other restrictions are in place (ie. you cannot currently have an outdoor public gathering, regarding of number of people, but you are allowed to bring your children to the playground where there are many other families). Figure 1 How would you rate the current public health measures to minimize the spread of COVID-19 through public playgrounds on a scale of 0 to 10 (0 is low and 10 is high)?

Supplementary Files
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