Child Wellbeing during COVID-19: A Cross-sectional Study from Pakistan

Background: The closure of schools because of the physical restrictions applied by the government has only amplified the hardships on children, parents, and teachers alike. Thus, this study aimed to assess parents’ perception of the impact of COVID on their young children. Methods: A cross-sectional survey was taken from the parents(n=128) parents of children ages 3-8 years, using a self-reported questionnaire. A tailored-made questionnaire google link was sent to the parents registered for the webinar. The link had all the details pertinent to the ethical considerations for the use of data. SPSS was used and p ˂ 0 .05 was considered statistically significant. Results: In total, 128 participants responded to the link sent to them via email and 122(95.3%) parents feared (high and medium) of sending their children back to the schools and out of which 110(85.9%) of them reported that they are confident in preparing their kids for the new everyday routine. Almost 75% of parents shared that the overall routine of the children is disturbed (directly or indirectly), and the children have started eating unhealthy food. Moreover, 51.6% (66/128) parents reported that mental issues (such as aggression and anxiety) have significantly ( p =0.027) risen amongst the children, and 39% (50/128) showed that learning has been negatively affected. Consequently, the children’s physical activity has significantly reduced, they get bored while staying at home and are not learning new things. Conclusion: There is a need to raise awareness about the detrimental impacts of the pandemic on early childhood development, learning, and wellness.


INTRODUCTION
The most prominent challenge children are facing in COVID-19 is the void of social interactions.Social interaction and play are the crux of childhood learning, growth, and wellness.School closures could significantly impact children's mental wellbeing and put them at greater risk, especially the children who belong to low-income families and have low-resources access in Pakistan [1][2][3][4] .
Pakistan has a large rural population.The challenges facing children in rural settings are primarily unknown, unexplored, undocumented, and lacking a focused governmental policy and approach to alleviating the problems.The pandemic has affected children from all spectrums, particularly those living in poverty and resource constraint settings.More than 1.5 million lived on streets across Pakistan in 2010, which is a rough estimate 5 .This number has definitively grown exponentially and is thus misleading today due to a lack of credible sources such as census to verify the figure 6,7 .These street children could easily contract the virus and will probably not have access to any form of healthcare 8 .Furthermore, the breakdown of social infrastructure due to the pandemic could negatively impact children 9 .Furthermore, UNICEF press release voices fear and concerns over millions of children who may resort to earning a livelihood or just the daily bread with child labor 1-4.On the other hand, children who did have access to schooling before the pandemic are now out of school, causing distress and challenges of learning and parenting at home 9 .Despite many challenges faced by the teaching and learning communities, online schooling platforms, and opportunities by the government, public and private platforms sprouted across Pakistan however, the access, usage, impact and success of tele-schooling is yet to be determined 10 .
The COVID-19 pandemic has also disrupted routine immunization of infants and children, forcing the country into polio, measles and other life-threatening diseases, despite adequate vaccine availability 9,11 .Predictions foretell that child morbidity and mortality will surge amidst the COVID-19 pandemic if concerted efforts are not made for urgent action 12 .The pandemic could further create more flawed living standards and worsen the economic statuses of up to 86 million children by the end of 2020 in lower-middle-income countries 13,14 .During the pandemic, it is also critical to ensure children and families increase handwashing and personal hygiene measures to avoid contracting the virus and maintain good health.The people will require constant support, education, and awareness to maintain hygiene, practice social distancing and protect their children 15 .
The COVID-19 pandemic has become more significant than a public health concern.It has laid bare the systemic failures of the modern world on many frontiers.Children and youth, who are the world's future, are at high risk of a poor start in life, which can lead to worse outcomes across their life span.It is critical to study and understand the problems, make sustainable action plans, rally public and private support to come together and protect our future.Thus, this research aimed to assess the perception of parents related to the impact of COVID on the children in Pakistan.

METHODS
This was a cross-sectional research based on a self-reported questionnaire.The survey was designed to identify parental perceptions related to the impact of the pandemic on the children's overall learning and wellbeing.The data collection was done as a part of a pre-webinar survey from the parents in Pakistan.The study received an ERC exemption from an ethical review committee of the Aga Khan University, Karachi, Pakistan.
The questionnaire was made using a web-based link using the Google forms platform.The research team made the questionnaire to identify the preliminary findings related to the COVID impact on their children.The participants who were to attend the webinar were sent these links via email before the webinar.The front page of the link had the consent note to participate in the study with all the required details relating to the purpose of the research to gain informed consent.This informed consent also ensured that the confidentiality of the participants would be maintained, and the required information will only be shared with the members of the research team (if necessary).
A self-made questionnaire was made to extract the Shafiq et al.
initial perceptions of the parents.No identifiable details were being asked to maintain the confidentiality of the participants.The questionnaire included the country of residence of the participants, concerns of parents related to sending their kids to school on the fear meter (high, medium or low), and questions related to the impact of COVID on children using a 5-item Likert scale (Strongly agree, agree, neutral, disagree, strongly disagree ).An open-ended question was asked at the end to get more detailed of the parents on the purpose of the study.Statistical analysis was performed using SPSS statistical software (SPSS Inc., Chicago, IL).Frequency and percentage were computed for qualitative observation.Mean and standard deviation has computed the sum of the product of score and count of the item divided by total [Average = (5N5+4N4+3N3 + 2N2 + 1N1) / 128].Chi-square and Fisher Exact test were used to analyze qualitative data.Significance was accepted at the 5% level.

RESULTS
In total, 128 parents answered the questionnaire.115 parents lived in Pakistan, four in the United Arab Emirates (UAE), two in Canada, two in the United States of America (USA), one in St. Lucia and one in the United Kingdom (UK).Three parents did not mention their country of residence.When asked about the fear of parents related to sending their children to schools during the pandemic, 47 (36.7%) reported their fear as high, 75 (58.6%)as a medium, and 6 (4.7%) as low using the fear meter.The confidence to take children out in the new normal which means wearing a mask and maintaining physical distance was also assessed.There were 25(19.5%)parents who were strongly agreed, 85(66.4%) agreed and 18 (14.1%)had neutral thoughts on the confidence on taking their children out to places like parks, markets and to visit their relatives (Figure 1).
Parents were agreeing that their child was scared due to COVID-19.The responses for the statement of the "child was scared" in parents who live in Pakistan compared to those who live in foreign countries as shown in Table 1.Statements from parents regarding the impact of Covid-19 on children and their disturbed routine were calculated with Mean±SD to obtain significant insights.There were 51.6% (66/128) parents who were agreed and strongly agreed that their child showed aggression, anxiety and other mental issues due to COVID-19.Some of the parents (22.7%, 29/128) were not agreed on such types of child issues and 36% (33/128) of parents' responses were neutral for this statement.A significant difference was observed in the responses of parents for the statement of children show aggression, anxiety and other mental issues between the country (p=0.027) as shown in Table 2.
The negative impact of child learning due to COVID was also observed, there were 39% (50/128) of parents were agreed or strongly agreed that their child's learning harmed COVID-19, 30.5% (39/128) were responded disagreed or strongly disagreed and 30.5% were neutral.All the responses regarding the statements were also not statistically significant between the countries (p>0.05).Agree and strongly agree on responses for the statement "my child shows a detachment from learning" was significantly high those parents who live in Pakistan as compared to other countries (p=0.048).The agreed and strongly agreed responses of parents regarding the "my child has increased screen time and disturbed routine" were significantly high in those who live in Pakistan (p=0.001) and (p=0.004)respectively.Disagree and strongly disagree responses regarding the relations with child had negatively affected was significantly high in parents who live in a foreign country as compared to Pakistan (p=0.032).

DISCUSSION
The cross-sectional survey included most of the responses from Pakistan; there was non-significant data from other countries.The findings depict that the parents fear sending their children to the schools during this pandemic.This fear may directly relate to the high contagiousness of this deadly virus.However, most of the parents were confident in taking their children out in the new normal.This might be because they can accompany their children while going out, which is not possible when sending their kids to schools.The impact of COVID-19 on children was evident per the parent's responses.Most parents reported that children have more screen inclined with a high prevalence of disturbed routines.It is observed that children are eating unhealthier foods and have shown a significant rise in mental health issues, including anxiety and aggression.
In addition to it, the learning of children has been dramatically affected; the children's physical activity has significantly reduced and children get bored while staying at home all the time.Also, the children are not involved in learning new things.However, most of them disagreed if the pandemic negatively affected the relationship of parents with their children.
COVID-19 has impacted children in a multitude of forms.It may be safe to assume many of the emotional and psychological impacts have yet to be discovered as children have been reported to respond quite differently in the aftermath of the extended lockdowns and limitations due to social distancing 16 .The uncertainty has given room to anxiety, which already challenged children and young adults in the fast-paced 21 st century 17 .Some of the primary causes and effects are outlined below to identify the problems and create opportunities for discussion and sustainable collective action among various stakeholders, including parents, schools, healthcare, and national policies to name a few.
The plausible reasons for the increased fear by the parents for sending their kids to school can be related to financial burden because of the wave of unemployment during the pandemic, the fear of overcrowding and increased risk of contracting the virus, and the fear of being away from the caregivers 18,19 .While the parents of the children were more worried about sending their children to schools.The recent report by UNICEF also highlighted that the children themselves are also very scared in going to schools [1][2][3][4] .The plausible reasons highlighted in this report included the mandatory requisites of the schools in the times of COVID-19 such as wearing protective clothing which is increasing unnecessary nervousness amongst the children.The Children's Health highlighted that sometimes, the continuous talks about the contagiousness of the COVID-19 do not allow children to distract their minds, ultimately leading to increased fear and anxiety 20 .The exact reasons can be attached to the parental fears in sending their kids to school.
A child's wellbeing is a multidimensional concept and rooted in emotional, social, psychological, physiological growth and development 21 .A child benefits from harmonious and holistic development to develop his faculties and innate abilities to their fullest.Chronic stress can become alarming, which can hamper a child's potential for learning, development, and welling 22 .The global pandemic has severely impacted child wellbeing and the wellbeing of all individuals for the matter.
Children were already navigating a world of new challenges -exposure to media, excessive screen time, and the internet -which created issues, such as obesity in adolescents and contributing to a sedentary lifestyle 23 .Screen time has also been associated with depression among children 24 .There is growing apprehension and research on the negative impact of excessive screen time due to COVID-19 on children's mental health with a risk of weakening eyesight among other physical and mental health problems 25,26 .There is growing research on the adverse physiological and psychological problems due to excessive screen time.
With school closures, many families have reported struggling to maintain regular routines at home.The disruption in routine has caused erratic sleep-wake cycles, meal times, physical movement and exercise among other problems harming child wellbeing 27,28 .Firstly, the extended school closures and secondly, the increased social distancing measures when schools resumed have created many challenges for the children.Most children have been missing the social interactions and closeness among friends and with adults.This has led to growing anxiety, mood swings, depression and feelings of loneliness and isolation.Detachment and boredom are also commonly found among children.They are unable to make productive use of their time due to confinement, busy parents, disengaged online lessons and lack of differentiated activities.The pandemic coupled up families at home, which has been reported to create problems such as violence against women and children 29, 30 .

CONCLUSION
There is a lack of awareness among parents and other stakeholders of children's developmental needs and problems stemming from the pandemic.There is a need for raising awareness and engaging parents and caregivers in learning activities to support themselves and their children.At the same time, the healthcare and education sectors and state policies must be reimagined to meet the challenges faced by children in these trying times.Educational campaigns and support from parents, teachers and support services must be stepped up to provide meaningful activities supported by a continuum of care.

Figure 1 :
Figure 1: Information of country, parents' fear meter and confidence level regarding COVID-19.