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Mothers' and children's thoughts on COVID-19: A qualitative study

Purpose This study aimed to investigate the thoughts of preschool children and their mothers about COVID-19. Design and methods This qualitative study was descriptive phenomenology design. Data were collected and analyzed through individual interviews from 26 people (13 mothers and 13 children) using a Personal Information Form and an Interview Form.After the thematic analysis, four main themes were created for the children and their mothers. Results The main themes created for mothers and children were: “Effects of the COVID-19 pandemic process, Protection, Family relations, Perspective of healthcare staff”. The COVID-19 pandemic has affected the physical, psycho-social, and economic health, spirituality and family relationships of mothers. It became evident that children knew the terms related to the COVID-19 pandemic. Children dreamt of activities they missed and stated that at the end of the COVID-19 pandemic, they would go to the park, the pool, shopping centers, to school, and on vacation. Most of the mothers and children followed the rules of protection. In addition, mothers and children stated that their perspectives on healthcarestaff changed positively after the pandemic started. Conclusions Considering that COVID-19 affects individuals bio-psycho-socially, it is crucial for health professionals to know the thoughts of individuals, families and children about COVID-19 to increase their awareness of potential problems.


Introduction
During this COVID-19 pandemic, when life in general has been spent mainly at home, most of the individuals confined to their homes have been children and their mothers. Compared to adults, children have faced such a situation for the first time and witnessed the pandemic through their parents' point of view and social media (Luttik et al., 2020;Tarkoçin et al., 2020;Yildiz & Bektas, 2021). This situation has made children more vulnerable to mental health problems. Each age group has different ways of understanding and coping with the COVID-19 pandemic (Demir Öztürk et al., 2020). The mothers, who are the primary caregiver, have an important place in children's understanding of the COVID-19 pandemic (Emir et al., 2020;Witt et al., 2020). Since mothers are the closest and most reliable information source for children, how they manage the pandemic is an important issue that needs to be examined. In addition to this, dual studies involving parents and children are needed to develop programs and interventions that better target family members' psychosocial needs. This study is essential because it presented a dual approach.

Background
In the city of Wuhan, China, cases of pneumonia of unknown cause were diagnosed in late 2019. These cases were found to be caused by a new type of corona virus (Wang et al., 2020;Zhu et al., 2020). The disease was defined by the World Health Organization (2020) as Coronavirus Disease-2019 (COVID-19). Due to the rapid spread of the COVID-19 virus and related deaths, a pandemic was declared on 11 March 2020. Since then, due to the human-to-human transmission of the virus, measures have been put into place such as wearing masks, closing schools, applying curfews, and canceling public meetings.
The new life style that has developed due to the COVID-19 pandemichas led to bio-psycho-social negativities such as fear, and physical and social isolation in individuals (Heymann & Shindo, 2020).
The Centers for Disease Control and Prevention (2020) reported that the measures necessary to prevent the virus from spreading can make people feel lonely and increase anxiety, stress and fear. Recent studies in the period of pandemic determined that parents with young children were suffering from high problems by social distancing and the complications that resulted from the closure of schools and childcares (Patrick et al., 2020;Perry et al., 2022;Wu et al., 2020). Children have also been greatly affected by this virus. For this reason, the pandemic should be managed well with this age group since children are developmentally sensitive in childhood (Tarkoçin et al., 2020;Yildiz & Bektas, 2021). It is difficult for preschool children to make sense of the COVID-19 pandemic as they act with an egocentric thinking system and have not yet acquired their abstract thinking skills (Derman et al., 2020;Yildiz & Bektas, 2021). The most important aspect in a preschool child's life is playtime. At this stage, developmental activities are crucial in order for children to gain bio-psycho-social skills. In particular, the change in children's daily routines may cause them to experience physical, mental, spiritual, and social problems. It can pave the way for the emergence of some pathologies such as anxiety, fear, and obsession. It is critical for parents to explain concepts such as viruses, mask wearing, and social distancing correctly to their children and present scientific information appropriate for their age so that such health problems do not occur/ progress (Ercan et al., 2020;Grady et al., 2021). They basically received information from the media as well as their parents, and they were aware of the terminology related to the COVID-19 pandemic. In another qualitative study, conducted by Tarkoçin et al. (2020), it was determined that since the COVID-19 outbreak, children's awareness of the disease had increased. They generally knew what COVID-19 was, they perceived the virus as dangerous, and they exhibited signs of anxiety, fear, aggressive/angry/aggressive behaviors, hyperactivity, sibling jealousy, and dependence on parents. Parents have been expected to explain this negative process and its consequences to their children and manage the fear and anxiety experienced by everyone in the family (Witt et al., 2020). Consequently, it is extremely important to investigate the perceptions of children and to take precautions.

Aim
The aim of this study was to investigate the thoughts of preschool children and their mothers about COVID-19.

Study design
This study was carried out in qualitative design using the descriptive phenomenology method to investigate the thoughts of preschool children and their mothers about COVID-19. Data were collected through semi-structured interviews. A Personal Information Form and an Interview Form were used as data collection tools.

Sample
The study was carried out in Erzurum province, which is located in eastern Turkey and is actively affected by the COVID-19 pandemic. A purposive sampling method was used to find 13 mothers and their 13 children ages 3-6 years participants for the study. The participants were recruited from the family health center providing primary care health services. Researchers invited mothers visiting the family health center to participate in the study. The content and purpose of the study were explained to the mothers. The date for the qualitative interview was decided with the mothers who having them agree to participate in the study.
The criteria for inclusion of them others were determined as having a child between the ages of 3-6. The criteria for children included being between the ages of 3-6, and having the level of perception and knowledge to understand/answer the questions. Children and mothers who met the inclusion criteria were interviewed until the data become saturated. The exclusion criteria for both the mother and her child and/or being an individual with special needs.

Data collection
Data were collected between November 2020 and April 2021.A pilot study was conducted by utilizing a draft interview form prepared as a result of reviewing relevant literature and giving expert opinions to two children and their mothers. According to the comments and answers, changes were made to clarify the questions. The purpose and importance of the study were announced to the participants in advance. The time of the interview was planned to suit the participants. Interviews were held at home in the garden, respecting pandemic measures such as mask wearing, social distancing and hygiene. With the permission of the individuals, the interviews were recorded and kept confidential. For each interview, 25-30 min were allocated to mothers and 10-20 min to children.
The basic interview questions provided to the mothers in the interview form were as follows: • What do you think about COVID-19?
• Has the COVID-19 pandemic affected your family's health or your own? Can you talk about the positive/negative effects? • What has the COVID-19 pandemic changed in your life?
• What kind of protective measures have you followed during the COVID-19 pandemic? • What do you think about practices such as hand washing, social distancing and mask wearing? • Has the COVID-19 pandemic affected your perspective on healthcare staff? What do you think about them? • How has the COVID-19 pandemic affected your family relationships?
The basic interview questions asked to children were as follows: • What comes to mind when you think of COVID-19? Where did you get this information? • What is a virus? What do you think it looks like? Do you think it's male or female? • What is a mask? Have you ever used one?
• What is social distancing? Can you explain it?
• How do you wash your hands? Whom did you learn this from?
• What are you doing to protect yourself from COVID-19?
• Who are healthcare staff? Do you know about them? What do you think about them? • What would you like to do when COVID-19 is over?
During face-to-face interviews with mothers and their children, mothers were allowed to be with their children. However, mothers did not interfere with their children's answers.
Techniques such as unconditional acceptance, active listening, and explanations were used to support the authenticity of the data and avoid bias. Data collection was terminated when similar answers were obtained by the 26 participants in the study and data saturation was reached (Saunders et al., 2018).

Analysis of data
Within 24 h of each interview, the researchers listened to and transcribed the recordings. Then, the data were analyzed using a phenomenological method. Two researchers independently reviewed and summarized the interview materials, revealing meaningful statements and forming themes. Thematic analysis was used while determining the themes. Thematic analysis is a methodical inductive analysis by identifying and bringing together the themes in the text, coding, classifying, and refining the categories (Vaismoradi et al., 2013). Accordingly, the themes/sub-themes in the study were derived from the available data. Hence, themes/sub-themes were created by constantly analyzing the data and having frequent discussions between the authors. Consensus among researchers was considered essential in the creation of themes/sub-themes.During the data analysis process, reliability criteria (reliability, transferability and confirmability) were adhered to (Guba & Lincoln, 2005). To increase data consistency, two independent qualitative researchers checked and confirmed the findings of the interview data analysis. The data analysis was based on the techniques of extracting themes from the qualitative data of Graneheim & Lundman, 2004): • First, all interviews were read several times by the researchers to get an idea of the general content of the text. • The text was divided into parts according to the units of meaning.
Condensed meaning units were labeled with codes. All encodings were checked a second time by the researchers. • The codes were interpreted and compared in terms of differences/ similarities, and the themes/sub-themes were finalized. • The statements of the participants were included in the context of the themes/sub-themes created for the descriptive analysis.

Study ethics
Before starting the study, approval (B.30.2.ATA.0.01.00/320-2020) was obtained from the ethics committee at ateaching university and research hospital. Verbal and written consent was received from the mothers participating in the study, both on behalf of themselves and their children. The purpose, content, and application process of the study were explained to the participants, and they were informed that they could leave the study at any time. The content, and purpose of the study were explained to the children in an age-appropriate manner. The interviews began with the children after acquiring their mothers' consent. During the interview with the children, their mothers were present. For the audio recording of the interviews, individual consent was obtained on behalf of the mothers and parental consent on behalf of the children.

The characteristics of participants
The mothers participating in the study were in the 25-34 age group, 7 of them were housewives and 6 of them were working. The children were in the 3-5.5 age group and included 5 boys and 8 girls.

Qualitative results regarding mothers and children
Four themes related to mothers' and children' perceptions of the COVID-19 pandemic process were determined by thematic analysis (Fig. 1).

Theme 1. Effects of the COVID-19 pandemic process
This theme was about the effects of the COVID-19 pandemic on mothers and children. It consisted of impact: psychological, physical, economic, social, and spiritual. Mothers stated that the COVID-19 pandemic had negative effects on them such as hopelessness, anxiety/ fear/panic, and obsession. However, positive effects such as hope and awareness were also experienced at times. Mothers stated that the COVID-19 pandemic had not affected their physical health. However, they indicated that they had delayed receiving medical help for health problems other than COVID-19 due to restrictions during the pandemic and the overburdened health institutions. Mothers stated that they had limited socialization experiences due to the COVID-19 pandemic. While some mothers stated that the economic situation of the COVID-19 pandemic had negatively affected them, some stated that their economic situation had been positively affected. During the COVID-19 pandemic, mothers said that they experienced their spiritual feelings more intensely and practiced their religious rituals more often. This study examined the impact of COVID-19 on children, how children perceived COVID-19 were analyzed. The children said that COVID-19 was a disease. They also defined it using gender, color, and shape for its physical characteristics. It was determined that the children dreamt about the activities they missed. Children stated that they wanted to go to the park, the pool, shopping malls, and on vacation once the COVID-19 pandemic was completely over.
The statements of the participants were as follows: We have a constant state of uneasiness. We are constantly washing our hands and walking around with masks… My social relations have weakened a lot. I started not being able to meet with the people I used to meet often.…this uneasiness makes us tired (M 3).
We understood the importance of time. I realized how beautiful our past experiences were, that going out is freedom (M 12).
It affected my mental health, it did not affect my physical health (M 6). It affected us very negatively. My husband works privately. When people didn't go out, they didn't shop and they didn't spend money. The product he was selling, was not bought. (M8).
Of course, it contributed spiritually. I devoted more time to my religious rituals. (M 7).
I would like to take trips and to go to the pool. (C 9). The virus is round, has needles. Color is red. I think the virus is male (C 1).
Color is green. I think the virus is female (C4). I missed shopping malls and buying the clothes(C6).

Theme 2. Protection
This theme was created to explain preventive measures applied during the COVID-19 pandemic and how they became part of a new lifestyle. Preventive measures for mothers and children were similar. It consisted of basic preventive measures such as hand washing, mask wearing, and social distancing. Mothers stated that the frequency and duration of hand washing increased and they used more soap/shampoo.Mothers stated that they paid attention to the use of masks. Mothers said that they followed social distancing rules, but often witnessed that other people who did not. Most of the children stated that they washed their hands for 20 s before/after meals, and when they came home from being out. Some of the children stated that they liked to wear masks, while others stated that it was difficult to wear them. Children stated that they knew and followed social distancing measures.
The comments of the participants were as follows: I used to wash my hands frequently, but now I wash my hands more often and longer than before (M 1).
I wear a mask because it is mandatory. It smells so bad. (M8). I try to practice social distancing with people. (M3). Social distance, the gap between us so that the corona does not come to each other's bodies. We must leave three or four… steps. (C 6).
I am using mask. I think using masks is fun and beautiful. (C 2). I'm scrubbing hard like this in the sink slowly all over (C 11). Theme 3. Family relationships Mothers stated that they mostly spent time at home with their families due to social restrictions. Some mothers stated that this had a positive effect on family relations and strengthened family ties, while others said that they experienced problems with their children/spouses. Children stated that they spend more time with their mothers and in the garden, since there is no school, and they do not go to their family elders. They said that they wanted this process to end. It was determined that the children missed the environments where they had social relations.
Some of the participants'statements were as follows: My husband is thoughtful or something, but heis never bearable!! He always asks me for something to eat. It's not good at home with kids. They are very tiring. (M11).
Normally, my husband would always come late, it was nice, we spent more time together. Here we built mosques and houses from matches with children. It was beautiful. (M 12).
When the illness is over, I will go to school first. I want to play with my friends. (C7).
I wish corona would end! I want to go to my grandmothers and hug them. (C8).

Theme 4. Perspective of healthcare staff
Mothers stated that healthcare staff worked under difficult conditions, were tired, and made sacrifices. Nevertheless, mothers thought that nurses did their jobs well. Children described healthcare staff as those who gave injections, dressed in white, worked in the hospital, and cared for patients. The children had more superficial perceptions than mothers about this.
The comments of the participants were as follows: In this process, we are not interbedded with the corona. But healthcare workers are always interbedded with corona. I can say that the most devoted ones are the healthcare professionals. (M4).
In this process, we declared them heroes and applauded them. I mean, we're glad they are there, what can we say. During this epidemic process, we have seen how well-trained the healthcare staff are. (M 6).
People who heal patients in the hospital. They wear white like this. They treat us. (C 12).
They are trying to end corona. I saw it on TV. (C13).

Discussion
This study's aim was to determine the thoughts, perceptions, practices, and changes in the lives of mothers and their preschool children during the COVID-19 pandemic and to understand the perspectives of mothers and children on healthcare staff.
According to the study, mothers and children tried to adapt to the COVID-19 pandemic and new lifestyle it established. The COVID-19 pandemic had effects on the psychological, physical, social, economic, and spiritual health of mothers.When the literature on the effects of the COVID-19 pandemic on mothers; Yoo et al. (2021) a qualitative study which analyzed the experiences of mothers with school aged children and determined that mothers experienced fear and anxiety about the COVID-19 pandemic and felt that their families were threatened. They stated that they were disappointed that the pandemic had not yet ended which affected them both physically and mentally. They realized how important human relations were to them. Kurt Demirbaş and Sevgili Koçak (2020), in a qualitative study with 30 parents, stated that parents experienced negative emotions such as uneasiness, fear, and anxiety the most, but there were also parents who experienced emotions of happiness.In another study, the majority of mothers talked about negative emotions, and very few of them mentioned that they experienced positive emotions (Yüksek Usta & Gökcan, 2020).The COVID-19 pandemic process has caused chain economic disruptions (The Economist, 2020).According to this study, the economic status of some of the mothers was adversely affected by the pandemic. Similarly, Choi et al. (2021), in a qualitative study conducted in New Zealand, found participants to experience financial stress.However, in another study conducted in Turkey, it was determined that 4 out of 30 families had financial difficulties (Kurt Demirbaş & Sevgili Koçak, 2020). During the COVID-19 pandemic, mothers were positively affected spiritually and practiced their religious rituals more frequently. A study conducted in Turkey confirmed that the spiritual feelings and hopes of individuals increased during the pandemic period (Gülerce & Maraj, 2021).
Preschool children tried to understand by concretizing as they had not yet acquired their abstract thinking skills. Most of the children in the study identified COVID-19 as a disease. According to Demir Öztürk et al. (2020), 14 children and most of the children who participated in their study to determine their mothers' perceptions of the pandemic defined COVID-19 as a disease. In a study conducted by Yüksek Usta and Gökcan (2020) with preschool children and their mothers, children correctly defined the COVID-19 pandemic and virus. According to Tarkoçin et al. (2020), the majority of preschool children were able to correctly explain the COVID-19 pandemic. In addition, children dreamt of going to the park, the pool, shopping malls, and on vacation. In another study, most of the children said that when the pandemic is over, they will go out freely and shake hands and hug (Yüksek Usta & Gökcan, 2020). Since children have not yet completed their developmental period and cannot meet their needs on their own, they may be more negatively affected by the COVID-19 pandemic process than other groups in society (Çaykuş & Mutlu Çaykuş, 2020). Negative conditions such as limited environment, lack of friends and limited playtime that emerged with the COVID-19 pandemic can adversely affect children's mental health. Children can constantly ask their families questions in order to understand the pandemic process (Abukan et al., 2020). It is essential to use correct communication techniques when responding to children and to inform them adequately to protect them from the negative effects of the COVID-19 pandemic (Dalton et al., 2020).
The mothers and children participating in the study took various measures. After the mothers felt the disease was a threat, they tried to protect themselves and their families by applying measures such as hand washing, mask wearing, and social distancing. These results paralleled the findings in the Yoo et al. (2021) study. Children participating in the study stated that COVID-19 was a disease and defined the concepts such as mask wearing and distancing as part of their daily lives. The study indicated that the children were knowledgeable about the terms and protective measures related to the COVID-19 pandemic, and they followed protective measures such as hand washing, mask wearing, and social distancing. In another study, similar results were obtained which determined that most of the children knew about protective measures (Yüksek Usta & Gökcan, 2020).
According to the mothers participating in the study, the COVID-19 pandemic had positive effects on family relations, such as spending more time together and strengthening family ties. However, there were also mothers who had more problems with their spouse/child as the time spent together increased. Children missed the environments where they had social relations and loved ones. Yoo et al. (2021) found that the more time mothers spent with their families, the more they experienced the feeling of family love. Similarly another study emphasized that during the COVID-19 pandemic, families contributed to the development of children by spending longer and more quality time at home with them (Çaykuş & Mutlu Çaykuş, 2020). Adverse conditions such as a limited environment, lack of friends, and lack of social interaction that has occurred because of the pandemic has affected the relationship of children ages 3-6 whose interests and curiosity towards the environment are at a peak (Ercan et al., 2020;Grady et al., 2021). In a study conducted with preschool children by Yüksek Usta and Gökcan (2020), it was observed that they developed negative feelings about the virus and were most affected by social isolation.
Mothers' and children's awareness and positive thoughts about healthcare workers increased during the COVID-19 pandemic. The mothers stated that the working conditions of the health workers were difficult, they were tired and they worked devotedly during this process. According to the findings of this study, children were knowledgeable about healthcare workers and the work they did. Children defined healthcare staff as people who gave injections, wore white, worked in hospitals and cared for patients. The frequent presence of healthcare staff in the media during the COVID-19 pandemic contributed to children's knowledge of healthcare staff. The COVID-19 pandemic has increased the work of inpatient treatment institutions and the need for more beds in intensive care units in hospitals. To meet the increasing needs of patients, healthcare staff have had to work more overtime than ever before. Healthcare staff have had to struggle not only with an increased workload, but also with the concerns of contacting/carrying the virus to their relatives (Çetintepe & Ilhan, 2020;Huang et al., 2020;Xie et al., 2020). In Turkey, at the beginning of the COVID-19 pandemic, healthcare staffwere applauded as a public movement to boost morale; healthcare staff were given more acknowledgement than ever before in advertisements, public service announcements and programs in the media. Therefore, these positive thoughts of mothers and children were expected.

Practice implications
These study findings have implications for healthcare professionals working with families during this pandemic. Considering that COVID-19 affects individuals bio-psycho-socially, it is crucial for health professionals to know the thoughts of individuals, families and children about COVID-19 to increase their awareness of potential problems. In general, it is possible to say that the COVID-19 pandemic affects mothers and children both positively and negatively. Due to the human-to-human transmission of the virus, the implementation of curfews, the closure of schools, the implementation of social isolation as much as possible, and the new life style affected the mothers and the children who were confined at home. It would be effective and beneficial for mothers who have adaptation problems to this new life and children who are in the developmentally sensitive group to seek help from health professionals in overcoming these problems.

Limitations
As this study only explores the experiences of preschool children and mothers during the COVID-19 pandemic, findings could differ depending on the individual's life stage. Therefore, its generalizability is limited. In addition, the study is limited in determining the COVID-19 pandemic effects on other family members.

Conclusion
Important findings were obtained in this phenomenological study, which aimed to investigate the thoughts of preschool children and their mothers about COVID-19. It concluded that mothers were affected physically, psychologically, socially, economically and spiritually. Preschool children tried to understand COVID-19 by concretizing. It determined that children knew the terms related to COVID-19 and dreamt about socializing after the pandemic. The study found that mothers and children tried to comply with protective measures, and their awareness of health professionals increased. It showed that the family relations of the mothers were affected positively and negatively.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
None.