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1. Introduction
Over the past two decades, the prevalence of acute respiratory infections has become one of the newest global health-related hazards and challenges [1]. In late December 2019, an outbreak of a coronavirus disease was reported in Wuhan, China [2].
This disease, called respiratory syndrome or the coronavirus disease 2019 (COVID-19), is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [3]. Following the global outbreak of the virus, the World Health Organization (WHO) issued a statement on January 30, 2020, declaring the new coronavirus to be the sixth leading cause of public health emergency worldwide that threatens not only China but also all countries around the world [4]. According to the WHO declaration, the number of global infections and deaths until January 31, 2021 was 103 and 22 million cases, respectively. Further, the number of confirmed cases and deaths in Iran was 1.4 million and 57 807 people, respectively [5]. COVID-19 is a coated virus with a ribonucleic acid genome [6]. COVID-19 infection was initially associated with nonspecific and general symptoms such as boredom, fatigue, body aches, fever, and dry cough. Patients may also manifest symptoms of nausea and diarrhea immediately before the fever. A small number of patients may have headaches or vomit blood and even be relatively asymptomatic. In the acute form, the disease begins with shortness of breath, and the subsequent decreased oxygen saturation leads to complications such as acute respiratory distress, kidney failure, heart failure, and even patient’s death [7]. People get infected when contaminated respiratory droplets spread through the infected person’s sneezing or coughing, land in the mouth or nose of people in proximity, and are subsequently transmitted to their lungs. Until large-scale vaccine production for the world’s general population is performed, the only ways to control this infection are personal protection, social distancing, and avoiding attending the contaminated environments [2].
Appropriate health measures are still considered primary disease prevention strategies in today’s civilized society, and achieving the desired health status in any society is one of the outstanding achievements in public
health [8]. Although measures have been taken to reduce
contact with or eradicate many pathogens in recent
decades, human susceptibility to several pathogenic
microorganisms is undeniable. Therefore, the constant
exploration of methods that can improve and maintain
optimal health should be considered. Indeed, exposure
to pathogenic microorganisms can occur because of
contact with infected people, contaminated water or
food consumption, contact with contaminated objects
or surfaces, or people’s unsanitary habits and behaviors.
In addition, group behavior is regarded as an important
factor in the process of disease transmission. Preventive
behaviors that can eliminate the disease transmission
cycle include washing hands with soap and water or
disinfectant solution, avoiding shaking hands and kissing,
disinfecting purchased items, wearing masks, and home
quarantine [9].
1.  Objective of the study
Considering the above statements, the critical COVID-19
disease conditions, and its negative effects on health,
economic, and social aspects that will ultimately have
adverse effects on the health and well-being of people
in the society and due to the need to perform protective
behaviors against COVID-19 and observe health
protocols, the aim of the present study was to investigate
the degree of adherence to environmental health
parameters for COVID-19 prevention in South Khorasan
province.
2. Materials and Methods
The present cross-sectional study was performed on
410 people residing in South Khorasan province. Data
collection was carried out using online questionnaires
considering the COVID-19 pandemic and its high
transmission risk. According to a study by Haghdoost,
when the prevalence or condition is not known, the
outcome frequency can be considered 0.5 to estimate the
maximum sample size. Therefore, due to the absence of
a similar study, considering the outcome value of 0.5 and
95% confidence interval, the sample size was considered
400 people [10]. After the approval of the research
project by the Research Council and obtaining the
ethics code of IR.BUMS.REC.1399.257, a questionnaire
using PorsLine program, which is a kind of tool to
create online questionnaire software, was prepared, and
the questionnaire link was sent to the online groups.
The completed questionnaires were analyzed after
reviewing the inclusion and exclusion criteria. The
inclusion criterion included voluntary answering of all
questionnaire items, and the exclusion criteria included
questionnaires that were completed more than twice
using the same ID and completion of the questionnaire
less than 5 minutes. The data collection tool included a
researcher-made questionnaire containing demographic
questions as well as questions related to the knowledge
and practice of individuals regarding the adherence
to environmental health parameters for COVID-19
prevention. The questionnaire validity was confirmed
using the qualitative content analysis method and the
opinion of experts including 7 health professors and 2
methodologists. To assess the questionnaire reliability,
it was given to 30 qualified people and Cronbach’s alpha
was calculated.
2. 1. Data analysis
In the present study, the collected data entered SPSS
version 16, and data analysis was carried out using
descriptive statistics (mean, standard deviation, and
frequency), analytical statistics, an independent t-test,
analysis of variance, Mann-Whitney test, and Kruskal-
Wallis test. Moreover, P value ≤ 0.05 was considered as
the statistically significant level.
3. Results
The study population included 410 subjects, of whom
35.9% were women and 64.1% were men. Table 1
shows the demographic information of the study
population. According to the results, 59.8% and 40.2%
of the participants were married and single, respectively.
Further, 36.3% of cases had diploma, and 32.4% of cases
were self-employed.
The overall mean and standard deviation of
participants’ knowledge scores regarding the observance
of environmental health parameters for COVID-19
prevention was 32.99 ± 5.01. Moreover, 55.4% of the
participants had COVID-19 disease, 82.9% of them wore
masks outdoors, and 75.1% did not wear gloves outdoors.
Table 2 illustrates the frequency distribution of answering
questions related to the knowledge regarding the level
of adherence to environmental health parameters for
COVID-19 prevention.
Table 1. Frequency distribution of participants’ demographic information in
South Khorasan province (n = 410)
Variable Categories Number Percentage
Gender
Female 147 35.9
Male 263 64.1
Marital status
Married 245 59.8
Single 165 40.2
Education
Elementary 60 14.6
Middle school 54 13.2
Diploma 149 36.3
Bachelor 113 27.6
Above Bachelor 34 8.3
Job
Employee 93 22.7
Self-employed 133 32.4
Manual worker 80 19.5
Housewife 43 10.5
Unemployed 10 2.4
Student/university student 51 12.4
Esform et al
228 Arch Hyg Sci. Volume 11, Number 3, 2022
The overall mean ± standard deviation of participants’
performance scores regarding the observance of
environmental health parameters in order to prevent
COVID-19 infection was 28.49 ± 4.60. A total of 48% of
participants kept a safe distance of about 1 to 2 meters
in a day in a few percent of cases, and 52% of them avoid
shaking hands. Table 3 displays frequency distribution
of answering questions related to performance regarding
environmental health parameters for COVID-19
prevention.
Statistical analysis revealed no significant relationship
between performance and demographic characteristics.
However, there was a significant relationship between
knowledge and gender (P = 0.006), education level
(P = 0.003), and job (P = 0.000). Table 4 shows results of
knowledge scores and the performance of participants in
terms of adherence to environmental health parameters
for COVID-19 prevention regarding demographic
variables.
4. Discussion
The aim of the present study was to evaluate the level
of adherence to environmental health parameters for
COVID-19 prevention in South Khorasan. The COVID-19
prevention has become one of the most important goals
of the health system worldwide. Unfortunately, due to
the lack of reliable and accessible information in most
developing countries, there is the greatest disagreement
about the root causes of the pandemic and how it changes
over time among different affected societies. However,
this information is crucial for strategic decisions about
COVID-19 prevention, but unfortunately, this disease
is spread through contact with asymptomatic carriers.
Therefore, defining comprehensive and targeted
COVID-19 prevention approaches is essential. The
study population included 410 people, of whom 35.9%
were women and 64.1% were men. Table 1 shows the
demographic characteristics of the study population.
Preventing COVID-19 requires adherence to personal
hygiene by all members of society [11]. In addition to
hand hygiene and safety distancing, one of the critical
and effective preventive measures against COVID-19 is
using masks. The present study revealed that 82.9% of the
participants wore masks outdoors. According to a study
by Lai et al, the use of masks can reduce the spread of
respiratory droplets from COVID-19 patients and help
control the disease [4]. Further, among the participants,
42% of people wore medical masks (surgical masks).
According to the WHO guideline, surgical masks led to a
significant reduction in the risk of infection among health
workers [12].
SARS-CoV-2 is transmitted through respiratory
droplets and close contact with people inflicted by
COVID-19 [14 ]. Therefore, one of the practical measures
to prevent the incidence of COVID-19 is creating desirable
indoor air quality via natural or mechanical methods
[14]. According to the results, 100% of the participants
Table 2. Frequency distribution of responses regarding the knowledge about
the level of adherence to environmental health parameters for COVID-19
prevention
Questions Answers Number Percent
Do you use masks outdoors?
Yes 340 82.9
No 70 17.1
Do you use gloves outdoors?
Yes 102 24.9
No 308 75.1
Do you observe 1 to 2 meters
social distancing outdoors?
Yes 323 78.8
No 87 21.2
Do you wash your hands with
hand sanitizer or soap on a
daily basis?
Yes 343 83.7
No 67 16.3
Is your home air conditioned
properly?
Yes 410 100
No 0 0
How air conditioning work in
your workplace?
Natural
ventilation
171 41.7
Ventilator, fan or
air conditioner
76 18.5
Both cases 163 39.8
Do you wear a mask
when traveling by public
transportation (such as buses
and taxis)?
Yes 227 55.4
No 92 22.4
I do not use 91 22.2
Do you disinfect your hands
after using a personal or public
vehicle (such as buses and
taxis)?
Yes 216 52.7
No 180 43.9
What kind of mask do you
wear outdoors?
Surgical mask 172 42.0
Filtered mask 101 24.6
Cloth mask 65 15.9
I do not use 66 16.1
What kind of gloves do you
wear outdoors?
Plastic 99 24.1
Latex 4 1.0
Fabric 9 2.2
I do not use 298 72.7
Do you wash your hands daily
with soap or hand sanitizer at
workplace?
Yes 239 58.3
No 67 16.3
Do you wear a mask at
workplace?
Yes 282 68.8
No 128 31.2
Do you wear gloves at
workplace?
Yes 81 19.8
No 329 80.2
Is the air conditioning working
properly in your workplace?
Yes 389 94.8
No 21 5.2
Do you use alcohol to disinfect
work surfaces?
Natural
ventilation
142 34.6
Ventilator, fan or
air conditioner
94 22.9
Both cases 174 42.4
How air conditioning work in
your workplace?
Yes 283 69.0
No 127 31.0
Do you use household
detergents to disinfect your
work surfaces?
Yes 152 37.1
No 257 62.7
Note. COVID-19: Coronavirus disease 2019.
Arch Hyg Sci. Volume 11, Number 3, 2022 229
Evaluation of Environmental Health Parameters for COVID19- Disease
had desirable ventilation conditions at home with natural
ventilation accounting for 41.7% of the cases. In addition,
94.8% of people had a favorable ventilation status at
workplace, where ventilation was performed by natural
and mechanical methods in 42.4% of the cases. A study
conducted in Moin hospital in Tehran demonstrated
the presence of this virus in the air of the wards and bed
surfaces of infected patients. Given the contamination of
the studied ICU with COVID-19, it is necessary to take
specific measures, including the implementation of air
isolation procedures such as using respiratory protection
equipment (e.g., N95 masks) and electric air purifier
masks as well as examining ventilation systems to ensure
the safety of healthcare providers [15]. A study on the
prevention of coronavirus in industrial environments
revealed that in crowded workstations, strengthening
ventilation systems had a significant role in controlling
the spread of coronavirus [16].
Timely and planned health activities include reducing
contact, observing the infected person’s contact with
others, quarantine, and physical distancing (the safest
physical distancing suggested to prevent disease
transmission is in the range of 1.5 to 2 meters) which
is very effective for the disease control [13]. The results
of the present study demonstrated that 78.8% of the
participants observed safe social distancing (1 to 2
meters) in the outdoor environment. The results also
showed that 73.9% of them had traveled in and out of
the city, attended party, and did not meet the quarantine
protocols. Therefore, this finding is inconsistent with
Stock et al qualitative study entitled “Risk assessment
of COVID-19 in China”. They showed that the most
Table 3. Frequency distribution of responses regarding level of performance
for environmental health parameter for COVID-19 prevention
Questions Answers Number Percent
What many time do you
observe the safe social
distancing (1 to 2 meters)
in a day?
(Rarely) 0-25% 101 24.7
(Sometimes) 25-50% 197 48.0
(Most of the time) 50% 97 23.7
(Always) 100% 15 3.6
How much do you avoid
shaking hands in a day?
(Rarely) 0-25% 45 11.0
(Sometimes) 25-50% 105 25.5
(Most of the time) 50% 213 52.0
(Always) 100% 32 7.8
I do not comply 15 3.7
How many times a day do
you wash your hands with
soap and water?
2 times or less 99 24.1
2-4 times 218 53.2
4-6 times 59 14.4
6-8 times 34 8.3
How many times do you
observe the separation
of indoor and outdoor
clothes?
(Rarely) 0-25% 104 25.4
(Sometimes) 25-50% 112 27.3
(Most of the time) 50% 96 23.4
(Always) 100% 98 23.9
How many times have
you traveled in and out
of the city or attended a
party during quarantine
conditions?
Rarely 106 25.9
5-10 times 110 26.8
10-20 times 103 25.2
More than 20 times 91 22.0
How many times have
you avoided contact
with people who have a
cold or a fever during the
pandemic?
Once or I did not pay
attention
153 37.3
2 times 100 24.4
3 times 82 20.0
More than 4 times 75 18.3
How much do you observe
basic hygiene items such
as avoiding shared utensils
last week?
(Rarely) 0-25% 81 19.8
(Sometimes) 25-50% 84 20.5
(Most of the time) 50% 109 26.6
(Always) 100% 130 31.6
I do not comply 6 1.5
How much better is your
adherence to hand and
face hygiene no than prepandemic
period?
(Rarely) 0-25% 29 7.1
(Sometimes) 25-50% 74 18.0
(Most of the time) 50% 225 54.9
(Always) 100% 82 20.0
How much do you deal
with the client in your
daily work?
less than 10 people 82 20.0
11-20 people 83 20.2
21-30 people 101 24.6
More than 30 people 51 12.4
I have no client 93 22.8
How many hygiene items
do you have access to and
use in a typical day at work
(hand washing - gloves -
mask - disinfecting surfaces
at workplace)?
None 16 3.9
1 Item 197 48.0
2 Items 103 25.1
3 Items 84 20.6
4 Items 10 2.4
Questions Answers Number Percent
How many minutes are
you in crowded places
on the way to work on a
typical day?
10 min 80 19.5
10-20 min 99 24.1
20-40 min 95 23.2
40-60 min 46 11.2
Over 1 h 1 2.0
None 89 21.7
How many times a day do
you use alcohol or other
household detergents
to disinfect surfaces at
workplace?
I do not use at all 116 28.3
1-3 times a day 280 68.3
3-5 times 12 2.9
More than 5 times a day 2 5.0
How many times a day do
you use alcohol or other
household detergents to
disinfect surfaces at home?
I do not use 102 24.8
1-3 times a day 263 64.2
3-5 times a day 35 8.5
More than 5 times a day 10 2.5
Since the onset of Covid-19
disease, how many times
have you taken and are
you aware of Covid-19
prevention measures?
(Rarely) 0-25% 98 23.9
(Sometimes) 25-50% 101 24.7
(Most of the time) 50% 116 28.3
(Always) 100% 95 23.1
Note. COVID-19: Coronavirus disease 2019.
Table 3. Continued
Esform et al
230 Arch Hyg Sci. Volume 11, Number 3, 2022
important control measure to reduce the risk of the
outbreak was arrival screening or travel restrictions [14].
Stock et al pointed to public health tools, including social
distancing, respiratory and hand hygiene, and quarantine
protocols, as very appropriate and effective measures in
delaying the COVID-19 peak [15].
The results revealed that 83.7% of people wash their
hands daily with liquid soap or soap, and there are better
hand and face hygiene conditions in 53% of cases as
compared to the pre-pandemic period. The results of the
present study are consistent with a study by Kanadiya et
al. The majority of them believed that washing hands with
soap and water reduced the risk of influenza, a type of
infectious disease of the respiratory tract [16]. Likewise,
Farahat et al found that hand washing as a preventive
behavior had the greatest effect [17].
According to the results, participants used alcohol or
other household detergents to disinfect surfaces at home
and workplace in 64.2% and 68.3% of cases, respectively.
Cadnum et al also found that ethanol solution and diluted
sodium hypochlorite disinfectant, which is electrostatically
sprayed, are effective and useful forms of disinfection
of equipment and surfaces [18]. Table 4 depicts the
relationship between knowledge and performance scores
regarding the level of adherence to environmental health
parameters for COVID-19 prevention with demographic
variables. Results demonstrated a significant relationship
between knowledge and gender, level of education,
and job. The results also indicated that the men had
higher knowledge than women regarding the adherence
to environmental health parameters for COVID-19
prevention, but women’s performance score was better.
In a study, Fallahi et al revealed that women had better
performance in observing home quarantine, which is one
of the COVID-19 preventive behaviors, and women had a
better understanding of social issues than men [19].
Moreover, housewives outperformed self-employed
women in terms of COVID-19 prevention. Indeed,
housewives accounted for 10.5% of the study population.
Further, 32.4% of self-employed people were men.
This being the case, it can be concluded that among
other contributors to the outperformance of women
is their occupation because men had to work outside.
In addition, 34.33% of studied people had a higher
knowledge level. Daniel et al found in their study that
students and parents are anxious about the current state
of the COVID-19 outbreak. Uncertainty about when
life will return to its normal status exacerbates their
anxiety symptoms [20]. Accordingly, it can be stated
that due to the closure of schools and universities or
their reopening only with a limited number of students
attending the classes, students were more aware of the
COVID-19 preventive behaviors than other groups.
Statistical analysis revealed no significant relationship
between performance and demographic characteristics,
suggesting that factors such as gender, marital status,
and education level cannot contribute to preventive
behaviors. This is inconsistent with Rahman & Sathi
and Zhong et al studies, which found that marital status,
education level, and occupation significantly predicted
preventive behaviors [21, 22].
5. Conclusion
The results of the present study demonstrated a
significant relationship between knowledge and gender,
level of education, and job. The results also indicated a
low level of knowledge and performance; therefore, it
is vital to raise awareness in this regard and change the
behavior of the general public. Decreased knowledge and
performance regarding disease prevention methods can
reduce effective performance and increase the incidence
rate. The study limitations included access of the target
group to online media due to the nature of the study’
accordingly, attempts were made to overcome this
limitation by using different online media. The results of
the study were also obtained based on self-administered
questionnaires, which may affect the results despite the
fact that the validity and reliability of the questionnaire
have been confirmed, so further research is needed to
confirm the findings of the present study.
Acknowledgements
This article is the result of a research project approved by Birjand
University of Medical Sciences with the ethics code of IR.BUMS.
REC.1399.257.
Authors’ contribution
Adeleh Esform wrote the draft of the paper.
Hamid Salehnia has been the statistical consultant of this project.
Ali Naghizadeh has been the Scientific supervisor of this research
project.
Conflict of Interests
The authors of the article state that there is no conflict of interests in
the present study.
Ethical Considerations
This study was approved by Research Council of Birjand University
of Medical Sciences and Health Services under ethics code of
IR.BUMS.REC.1399.257
Funding/Support
This study was funded by the Department of Education and Research
of Birjand University of Medical Sciences (no. 5458).
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