FACTORS ASSOCIATED WITH THE LEVEL OF KNOWLEDGE OF COVID-19 PREVENTIVE MEASURES IN PREGNANT AND PUERPERAL WOMEN IN TWO PERUVIAN COMMUNITIES

The factors associated with the level of knowledge of the preventive measures of COVID-19 in pregnant and postpartum women from two Peruvian communities were determined. Quantitative, prospective, cross-sectional and analytical study. They worked with the entire population. The level of knowledge was measured through a previously validated instrument. Bivariate and multivariate analysis was performed, using linear regression with a 95% confidence interval. The results indicate that the majority (64.7%) considered the use of rubber gloves as a preventive measure, while 33.8% considered the use of homemade masks incorrect and considered that domestic animals transmitted COVID-19. In the multivariate analysis, the level of knowledge was associated with having received information from their health center. There is a good level of knowledge about COVID-19 prevention in pregnant and postpartum women from two Peruvian communities, and that the main associated factor is having received information from their Health Center.


INTRODUCTION
At the end of December 2019, a new disease of unknown etiology appeared in Wuhan, China. It was rapidly identified as a new betacoronavirus and it was related to SARS-CoV, among other coronaviruses similar to SARS transmitted by bats. This new coronavirus species caused a great amount of cases and diseases in China and an increasing amount out of it (1) .
There is still no scientific evidence that shall permit a specific treatment against this infection. Thus, in this situation the use of preventive measures is compulsory in order to avoid the propagation of the disease. At the present time, preventive measures recommended by the World Health Organization (WHO) include different aspects, from frequent hand washing, avoid agglomerations, to cover the mouth and nose with masks, social distancing, avoid to travel to affected cities and areas, and the isolation of people at the moment they start to present symptoms associated to COVID-19 (2) .
The current pandemic due to COVID-19 has generated various health facilities to collapse, this led to prioritizing health care in cases of urgency and emergency. Among the services provided are maternity services, decreasing the provision of services and threatening the well-being of the pregnant women. Pregnancy may compromise the immune system and increase the risk infection for COVID-19. Likewise, the presence of ACE2 receptors in the placenta may increase the risk of vertical transmission of the virus from mother to the child (3) .
In a pandemic situation, prevention is one of the pillars to fight against it (4) . Therefore, our objective is to determine associated factors with the level of knowledge of preventive measures of COVID-19 in pregnant women and puerperals of two Peruvian communities.

THE STUDY
Quantitative, prospective, transversal and analytical study. The population in this study consisted of pregnant women and puerperals in two Peruvian health centers, one of them located at a marginal urban area in Chorrillos, Lima, called Centro de Salud Delicias de Villa, and the other one in a rural zone of the province of Utcubamba, Amazonas, called San Juan de la Libertad. A sample size was not calculated since we worked with every pregnant woman and puerperal of the corresponding health center census.
The information was collected through survey techniques in pregnant women and puerperalis that were performing their controls, due to the pandemic context and the healthcare situation in medical centers of first level. The data collection and questionnaire filling through telephone and it was realized during September and October, 2020. The main variable was the level of knowledge about preventive measures against COVID-19. Research study consisted of a survey that measured the knowledge of preventive measures against COVID-19 and included 16 questions of general knowledge about prevention. Each question had a Yes, No and I have no idea answers. Maximum score was 32 and the minimum score was 0.
The validation of the instrument of investigation consisted, in the first instance, of a judgement between four experts, three doctors and a Licensed in Obstetrics with speciality in health promotion and prevention. All of them have more than five years of experience in health primary attention. Later, a pilot test was performed in 51 pregnant women, from which Crombach's alpha was calculated, aiming to obtain data in order to measure the reliability of the instrument through estimation of intern consistency, obtaining a coefficient of 0.62. Other variables such as age, district, gestation weeks, prenatal control number, occupation, number of children, civil status, degree of instruction were also obtained via telephone.
Excel program was used in order to enter data of telephone surveys. The statistical analysis was performed using the statistical program Stata 14.0. Quantitative variables were described through central and dispersion trend measures. The bivariate analysis was performed from the Mann-Whitney U test or Spearman correlation, as appropriate, given the unusual distribution of the quantitative dependent variables, it was considered an statistically significant value if it was less than 0.05. To multivariate analysis, linear regression was used to obtain the regression coefficients and its respective 95% confidence intervals. This research was evaluated by the ethics committee of Universidad Ricardo Palma, and after being approved, proceeded the data collection through via recorded telephone, where the reading of informed consent was emphasized, and it was mentioned that the person is able to terminate the survey at the moment she considers it pertinent without any repercussions of any nature in its prenatal controls.

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Thus also no economic compensation was contempled. The application of informed consent was recorded with the knowledge of the respondent. After the telephonic survey, it was performed a little informative talk about the preventive measures for COVID-19 in every pregnant woman and puerperalis which were attended.

FINDINGS
In Table 1, it is observed that the majority of participants are housewives (74.6%) and single (54.4%). Thus also, the most frequent education level was Secondary (63.2%), as well as other characteristics.
In Table 2 it was founded that questions 4 and 10 obtained the greatest number of correct answers. On the other hand, question number 8 obtained the greatest number of incorrect answers.
In Table 3 it is observed that the majority of participants who received information saw it through    social media and TV, radio or written press.
In Table 4, it was found that there is a significant association between the level of knowledge and source information obtained by the health center in the multivariate analysis.

DISCUSSION
In general, a good level of knowledge about the prevention of COVID-19 has been found in the population evaluated, unlike that found in other studies in Latin America (5,6) , where the groups of pregnant women presented insufficient knowledge; which manifests itself with excessive concern about the disease.
There are some points where there were a great amount of wrong answers. One of them is the use of rubber gloves in public places, in which the majority considered that it is a measure to prevent COVID-19. However, their community use is discouraged, since they do not prevent potential contamination of the person from hand contact. On the contrary, if it is quite clear that hand washing is one of the main means to prevent COVID-19, as well as avoiding crowds and maintaining social distance (7) ; However, it should be mentioned that almost a third of the population was not clear about the importance of the use of cloth masks, which are recommended for community use; Therefore, it is necessary to emphasize the importance of the use of cloth masks for the prevention of COVID-19 (7) .
Also, there is no current evidence to indicate that domestic animals can transmit the disease. However, as pets need to walk, it is possible that they act as vehicles for the virus, especially if they had contact with contaminated surfaces, so it is important to emphasize good pet hygiene (8) .
On the other hand, the good level of knowledge found probably has to do with the good informative work carried out by the Health Centers, this is evidenced in the association, even in the adjusted model, of the level of knowledge with the source from which it is received the information from the Health Center. It is important that the sources of information come from legitimate means, capable of providing verified and correct information on the prevention of COVID-19; being the health personnel one of them. It is important to strengthen the work of health promotion and prevention, since it is one of the main tasks carried out in these Health Centers, focused mainly on primary care; since, although it was the one that was associated with the best knowledge, it was not the main source of information.
The most common sources of information in the population studied were social networks and information through television, radio or written press. This result agrees with the results of the study carried out by Bhagavathula AS et al. (9) , where it is reported that the most common source of information for the participants was television (82.7%), followed

ORIGINAL SHORT
Pág. 136 by friends and family (78.5%). Health and Internet workers represented 39.8% and 44.7% of the participants' information sources, respectively. This is relevant because the information that normally circulates through social networks is not necessarily verified information; indeed, its interactivity allows a potential dissemination of fake news and hoaxes that could rather harm people's health (10) . On the other hand, the traditional media, such as radio and television, do not escape this practice, having evidenced cases of dissemination of information that is not verified or that contradicts what scientific research normally reports (10) .
Unlike other studies (5,6,11) , no relationship was found between the level of knowledge with maternal age, gestational age, educational level, area of residence, among others. However, it is striking that in the bivariate analysis, an association was found with the marital status of cohabiting or married of the pregnant or puerperal woman, which would indicate that the couple's relationship could positively influence knowledge; This could be in agreement with the finding of Maharlouei et al. (12) , who found an association between the level of knowledge and the duration of the couple's relationship.
Within the limitations of the study, there was a small sample size, which probably could have increased the probability of committing a type II error in some variables evaluated.

CONCLUSION
It is concluded that there exists a good level of knowledge about prevention against COVID-19 in pregnant women and puerperals of two Peruvian communities and that the principal associated factor is because they received a great amount of information from their Health Center.