{'fraction_non_alphanumeric': 0.02391992345624494, 'fraction_numerical': 0.01950393758739972, 'mean_word_length': 5.033747779751332, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
The relationship between COVID‐19 knowledge levels and anxiety states of midwifery students during the outbreak: A cross‐sectional web‐based survey

Abstract Purpose To determine the relationship between the anxiety states and knowledge levels of female midwifery students about COVID‐19 during the outbreak. Design and Methods This cross‐sectional study carried out with online participation of 972 female midwifery students. Findings The anxiety levels of the female midwifery students were high among those visiting the hospital during the pandemic and having parents or relatives who had chronic diseases. Female midwifery students had a high level of knowledge regarding COVID‐19. Practice Implications Female midwives of the future will take part in primary health care services in the protection and promotion of health as an important occupational group in the public health system. To determine mental health and psychological needs of them during the outbreak will greatly contribute to the pandemic management process.


| INTRODUCTION
The coronavirus disease which started in China was declared as a pandemic by the World Health Organization on 11 March 2020 1 (Coronavirus). The coronavirus disease (COVID-19) is a contagious disease caused by a newly discovered coronavirus and detected by pneumonia clusters. This disease was first detected in Wuhan, China.
Later, it was seen in Japan, Thailand, the USA, Australia, and France.
Preventive health measures have been taken on 11 March 2020 after the appearance of the first cases in Turkey. The number of cases and deaths is increasing day by day. 2 The coronavirus disease, like other pandemics, is predicted to cause serious mental health problems among communities and health workers. 3,4 As a global public health problem, the coronavirus disease has become a pandemic that has caused the death of many people and led to great economic losses worldwide. 5 COVID-19 is a rapidly spreading disease that is highly contagious, resulting in death in severe cases, and does not yet have a vaccine and treatment 5 . At the time of this study, there were 110 000 cases and more than 4000 death. Clinical findings develop like any upper respiratory infection. Having a strong immunity plays an important role in the mild recovery of the disease. 6,7 Most people infected with the COVID-19 virus experience a mild to moderate respiratory disease and recover without special treatment. Elderly individuals and those with underlying medical conditions, such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer, constitute the risk group for COVID-19. The risk of death increases with increasing age. 8,9 Infection with breast milk in children has not been reported so far. It was found that COVID-19 did not pass from mother to baby before and during the birth. 10,11 The primary purpose of health services is to ensure that individuals continue to live healthily and to prevent diseases. Outbreak management is one of the most important public health practices in maintaining health and preventing infectious diseases. Health professionals have many heavy responsibilities such as working in healthcare services, educating the society about the infectious disease, prevention methods, 12 and conducting community mental health studies during the prevention, and slow down processes of the pandemic. Health professionals are also at great risk due to the pandemic. More than 76 000 cases of COVID-19 have occurred in China so far, and more than 3000 of them have been healthcare professionals. 5 In addition to taking personal protective measures against the epidemic, healthcare professionals should also take measures to protect their mental health.
Managing the mental health and psychosocial well-being of healthcare workers during the outbreak is as important as managing their physical health (Mental Health Considerations). 5 Fear, apprehension, and anxiety also occur in healthcare professionals during epidemic periods when they themselves face the risk of death. After the Covid-19 pandemic, some organizations that are working on improving the mental health of society have published guides 13,14 and recommended online therapies. 15,16 Traumatic events 17 and being closed at home during epidemic periods 18 increase the likelihood of anxiety. The preference of maladaptive coping mechanisms used to deal with this situation further deepens the anxiety experience. 8 Female adolescents are more likely to experience anxiety than male peers. In addition to the impact of COVID-19 outbreak, female midwifery students are one of the risk groups for anxiety regarding their age. [19][20][21][22] When the literature is examined, studies on the probability of experiencing anxiety and COVID-19 knowledge levels of female midwifery students, who have to stay at home during the epidemic as members of the society and follow the literature closely as candidates to take part in health services in the future, are limited.
In this context, this study was conducted to determine the relationship between the COVID-19 knowledge levels of female midwifery students and their anxiety states during the pandemic. This study was designed as a cross-sectional study that covers all female midwifery students in Turkey. Through the Midwifery Student Commission of the Anatolian Midwives Association, ∼10 000 female midwifery students were invited to participate in the study between 15 and 30 March 2020 by sharing the prepared online form with a messaging application. A total of 972 female midwifery students participated in the study and the rate of return is 9.7%. The data began to be collected after the first coronavirus-infected cases began to appear and the government demanded the public to stay at home.

| Measurements
The "Survey Form" and the "Beck Anxiety Inventory" prepared by the researchers through scanning the literature were used to collect the data of the research. Correct answers given to the knowledge measurement questions are scored as 1 point, and participants can get 0 to 18 points in total.

| Beck anxiety inventory
It is a self-assessment scale developed by 23  reported to be .93, 24 whereas the Cronbach's α coefficient was .90 in the internal consistency analysis in the present study.

| Ethical considerations
Ethical approval (decree code: 2020/0046) was obtained for this research work from the ethics committee of the University where the second author worked before commencing the study. We informed all participants about the aim of the study by sending them an e-mail and invited them to attend the study. To ensure the confidentiality of participant information, we did not include any identifying information in the online questionnaire.

| Statistical analysis
We used SPSS for Windows version 25.0 for the statistical analysis of the research data. The normality of the distribution of the data was evaluated using Shapiro-Wilk values. We performed frequency, percentage, mean, and standard deviation for reporting demographic data of the participants. Additionally, independent samples t test and analysis of variance were used for comparing the continuous data averages. and to pray (59.5%) for coping with coronavirus infection diseases.

| RESULTS
As is shown in Table 1, The majority-female midwifery students (94.4%) had low anxiety, followed by moderate anxiety (4.5%) and potentially concerning levels of anxiety (1.0%). There was a statistically significant difference in BAI score according to presence of chronic diseases among female midwifery students' parents or relatives (t test = 3.260; P < .05) and students visiting the hospital after coronavirus outbreak (t test = 1.893; P < .05) ( Table 1).
As depicted in Table 2, we present Pearson correlations among BAI score and knowledge level of coronavirus infection. We did not find a significant correlation between BAI score and knowledge level of coronavirus infection (r = −.0275; P = .39) ( Table 2).

| DISCUSSION
In this study, it was investigated whether there was a relationship between the anxiety status of the female midwifery students and their sociodemographic characteristics, the changes they experienced in daily life due to coronavirus, and their levels of knowledge According to the studies conducted, the frequency of anxiety among young people has increased rapidly in recent years due to external factors such as success pressure, social media, and the widespread use of the internet 20,22,25,26 as well as many complicated reasons within the family. 27 Anxiety rates because of diseases are also higher in young people, affecting the majority people, 28 and such conditions may be the onset of mental illnesses for older ages. 29 Especially, the prevalence of anxiety is more prevalent among female adolescents compared to male agemates. [19][20][21][22] The average age of the female midwifery students participated in the study was about 21%, and 94% of them experienced a low level of anxiety and 5.5% of them Studies show that diseases that cause great destruction in societies, such as coronavirus, increase the anxiety rate of humans. 4,8,31 According to a study conducted by the Mental Health Association (MHA) in our country, the statements of the participants showed that 50% of the society were afraid of being infected by coronavirus; that 59% of them increased anxiety about their health; that 61% of them increased anxiety about their future; that 48% of them had increased feelings of restlessness; that 64% of them began to fear more from diseases; and that 59% of people began to be annoyed more by the symptoms of the disease (MHA, 2020). 32 According to the study conducted by Huang and Liu 9 on emotional response and coping methods developed against the coronavirus disease in nurses and nursing students, students' anxiety levels related to the coronavirus disease were found to be lower than nurses. In this study, 94.4% of the female midwifery students were found to have low anxiety levels.
It was observed that the female midwifery students with chronic illness in their parents or relatives experienced more anxiety about the coronavirus disease. People with chronic health conditions such as cardiovascular disease, diabetes mellitus, asthma, chronic obstructive lung diseases, chronic kidney diseases have a high risk to be infected and emerged severe outcomes of COVID-19. [33][34][35] The high level of anxiety in female midwifery students whose parents or relatives had chronic diseases could be explained by this increased risk.
87% of the female midwifery students in our study started to follow the media after the coronavirus disease cases started to appear, and this rate was 72% in adults in the society (MHA, 2020). 32 Studies show that the intenseness of the news in the press after major disasters increases the level of anxiety in people. 4,36 However, in this study, 5% of the students in Turkey were found to have moderate or high levels of anxiety. It is evaluated that most of the cases with a low anxiety level may be due to the precautionary measures that the students take in their home environment. Additionally, the majority of people in Turkey are Muslim 37 and previous studies reported that there is a significant relationship between religious behaviors and anxiety level in adolescents. 38

| CONCLUSIONS
These study findings demonstrated that the anxiety levels of the female midwifery students who applied to a hospital after the COVID-19 outbreak and who had chronic diseases in their parents or relatives were higher. However, there was no significant relationship between the other variables examined in the study and anxiety levels. It has been observed that only 5% of the female midwifery students have moderate or high levels of anxiety. The relationship between the anxiety and coronavirus knowledge levels was not statistically significant.
This study was conducted at the beginning of the COVID-19 outbreak in Turkey and there were few CIVID-19 cases. Midwifery education was interrupted, and students were at their home where was a safe place to be protected from the COVID-19. These two situations could be asserted as reasons for experiencing a low level of anxiety. The psychological impact of outbreaks on individuals and society is inevitable and these psychological consequences may continue for a long time after the outbreak ends. Therefore, further studies are recommended to be conducted in the late stages of the crisis and after the COVID-19 outbreak.

ACKNOWLEDGMENTS
The authors are grateful to all participants who agreed to participate voluntarily in this study.

CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.

RELEVANCE FOR CLINICAL PRACTICE
COVID-19 is an important global health problem that has a major impact on both individuals and society. Different individuals and groups may experience different levels of psychological crisis, but health professionals are fundamentally affected. Female midwives of the future will take part in primary health care services in the protection and promotion of health as an important occupational group in the public health system. It is very important for female midwives to manage their own apprehension and anxiety to provide healthy psychosocial care to pregnant women they will give care to before, during and after birth. Descriptive studies for the determination of mental health and psychological needs of midwifery students during the outbreak will greatly contribute to the pandemic management process.