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\begin{document}

\title{Patient attitudes towards universal COVID-19 screening: A survey of
pregnant women undergoing universal screening at an East London Hospital}



\author[1]{Neha Shah}%
\author[1]{Samreen Wasif}%
\author[1]{Richa Gupta}%
\author[1]{Ferha Saeed}%
\author[2]{Stamatina Iliodromiti}%
\author[1]{Luxmi Velauthar}%
\affil[1]{Newham University Hospital NHS Trust}%
\affil[2]{QMUL}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective To explore patients' attitudes and acceptability of universal
screening for COVID-19 in a maternity population. Design Pre-screening
and post-screening patient surveys Setting London Population Women
admitted to the Maternity Unit at Newham Hospital during a two-week
trial period of universal screening. Methods Cluster random sampling was
used to select participants to complete the pre-screening questionnaire.
Post-screening questionnaires were performed over the telephone. Main
outcome measured Agreement to statements regarding patient's
acceptability of the SARS-CoV-2 screening test and the impact screening
had on the care provided to themselves and their babies. Results During
the two-week period, 180 women underwent universal screening. 81
participants completed the pre-screening questionnaire and 79
participants completed the post-screening survey (72-85\% completion
rate). More than 70\% of women agreed that routine screening resulted in
a positive effect on their care, the care of their babies and on their
families. More than 80\% of women agreed that they would be happy with
their care if all pregnant women were offered testing for COVID-19 on
admission to hospital. However, 50.62\% of women agreed that having a
COVID-19 screening swab test taken was uncomfortable and 35.80\% were
worried about the test results. Nulliparous women were more likely to
perceive the positive impacts of screening on their care, their babies
care, and their families as compared to multiparous women. Conclusion
Our study provides evidence that patient acceptability and tolerance to
COVID-19 screening is high, which is key for future implementation of
universal screening across maternity services in the UK.%
\end{abstract}%



\sloppy


\emph{}

\emph{Introduction}

COVID-19 is caused by the severe acute respiratory syndrome coronavirus
2 (SARS-CoV2).\textsuperscript{{[}1{]}} Since first being identified in
December 2019 in China\textsuperscript{{[}2{]}}, it has spread globally,
becoming recognised as a global pandemic on 11 March
2020.\textsuperscript{{[}3{]}}The first confirmed case in the United
Kingdom (UK) was on 31\textsuperscript{st} January
2019\textsuperscript{{[}4{]}}, and since then there have been over
210,000 further cases with more than 31,000
deaths.\textsuperscript{{[}5{]}} Social distancing and the widespread
lockdown has reduced the reproducibility of the virus and controlled the
exponential increase in the spread of the infection in the UK.
Nevertheless, the virus is likely to remain in the community, and
therefore, a viable and safe exit plan from the lockdown is required,
without increasing the risk of a second peak.

National guidelines for COVID-19 screening rely on testing symptomatic
individuals who display persistent cough or
fever.\textsuperscript{{[}6{]}} Whilst most cases of COVID-19 are spread
through symptomatic individuals, there is accumulating evidence that
transmission can occur from pre-symptomatic individuals (SARS-CoV-2
detected before symptom onset) or asymptomatic (SARS-CoV-2 detected but
symptoms never develop).\textsuperscript{{[}7{]}} Therefore, widespread
testing for SARS-CoV2, to interrupt an otherwise undetected transmission
chain and to fill critical knowledge gaps about the incidence of
asymptomatic COVID-19 in the UK population is urgently required in order
for the lockdown to end safely.

Pregnant women have been characterised as a vulnerable group for
developing a severe infection\textsuperscript{{[}8{]}}, however, they
cannot fully shield because of the multiple encounters with maternity
services as part of their routine care. Therefore, the challenge of
asymptomatic SARS-CoV-2 transmission can be associated with even greater
implications in a pregnant population with the risk of transmission to
their new-borns, other expectant mothers and health care workers (HCW)
rendering control of the pandemic more difficult.

Newham has had the highest age-standardised mortality rate for deaths
involving COVID-19, with a rate of 144.3 deaths per 100,000 between
1\textsuperscript{st} March 2020 and 17\textsuperscript{th} April
2020.\textsuperscript{{[}9{]}} We therefore commenced a universal
testing pilot for SARS-CoV-2 for two weeks at Newham University Hospital
(NUH) in East London. In order to inform public health policymakers, we
were interested in how universal testing was perceived by patients.

The aim of our study was therefore to explore patient's attitudes and
acceptability of universal screening for COVID-19 in a maternity
population.

\emph{Methods}

All inpatients to the maternity unit were offered the SARS-CoV-2
nasopharyngeal swab test from 22 April 2020 to 5 May 2020. Details of
patients who had the swab taken were recorded in a secure electronic
database to ensure follow-up. Results were made available within 12-24
hours, at which point patients were informed of their result. Those who
tested positive were managed and given self-isolation advice
accordingly.

The patient questionnaire was developed by a focus group of
Obstetricians, after performing a literature review and evaluating
previously published patient satisfaction
tools\textsuperscript{{[}10-15{]}}. In particular, the questionnaire was
adapted from the validated HIV universal screening
toolkit.\textsuperscript{{[}15{]}} The first half of the questionnaire
included questions on patient demographics. The second half explored
attitude towards COVID-19 and screening where responses were rated on a
five-point Likert scale from ``strongly disagree'' to ``strongly
agree''.

Cluster random sampling was used to select participants to complete the
anonymous pre-screening questionnaire, with all eligible patients'
beings offered the opportunity to complete the survey at set points
during the screening period. This was performed before the patient was
informed of their SARS-CoV-2 test results. A post-result survey was
performed over the telephone with the same questions asked to re-assess
attitudes towards SARS-CoV-2 and screening. Follow-up began seven days
after the result became available. If contact was not possible,
reattempts were made up until day ten. At the time of data analysis, the
first 110 women to have undergone universal screening were within the
allocated time frame to assess post-screening attitudes and therefore
were included in the study. This timeframe was chosen to allow
sufficient time for screened women to have returned to their normal
daily routine and make the necessary adjustments in their households.
All completed questionnaires were collected by maternity staff and
entered onto an electronic database without any patient identifiers to
ensure anonymity.

As this was an anonymous service evaluation, ethics approval was not
required. The study was registered under the local clinical
effectiveness team and underwent review by the COVID-19 Committee.

\emph{Statistical analysis}

All statistical analyses were performed using the IBM SPSS version 26.
Differences in characteristics of the patients between the two groups,
that is, the pre-screening and post-screening cohorts were compared
using the independent sample t-test for the continuous variables and the
Chi\textsuperscript{2} test for the categorical variables. Multivariate
Analysis of Covariances (MANCOVA) was used to determine if there was an
association between any of the demographics and the perceived ratings of
the opinion statements.

\emph{Results}

During the two-week period, 180 women underwent universal screening.
Random sampling in the week following the introduction of universal
screening selected 95 women, of which 81 completed the pre-screening
questionnaire (85.26\% completion rate). Of the 110 women eligible for
the post-screening telephone survey, 79 participants completed the
survey (71.82\% completion rate). Reasons for non-completion of the
pre-screening survey included active labour deterring completion of the
survey, with the language barrier being a reason for non-completion of
the post-screening survey.

Patient demographics for both the pre-screening and post-screening
cohorts are presented in Table 1. There was no statistical difference
between the groups in terms of parity, occupation, highest education
level, ethnicity, and ability to speak English. Nevertheless, there was
a statistically significant difference between home occupancy between
the pre-screening cohort (mean=3.21, SD = 2.338) and the post-screening
cohort (mean=4.86, SD = 2.453), p = \textless{}0.05.

On the pre-screening questionnaire, 82.72\% of participants agreed or
strongly agreed that they would be happy if the maternity unit offered
screening for all pregnant women for COVID-19 on admission to hospital,
with 12.35\% disagreeing or strongly disagreeing. 93.83\% of
participants agreed or strongly agreed that having the COVID-19 test
would have a positive effect on the care provided to both themselves and
their babies, with 1.23\% disagreeing or strongly disagreeing. 88.89\%
of participants agreed or strongly agreed that the test would have a
positive effect on their families, with 3.70\% disagreeing or strongly
disagreeing. The remaining participants neither agreed nor disagreed
with the above statements.

The post-screening questionnaire showed that 94.94\% of participants
agreed that they would be happy if their maternity unit offered
screening to all pregnant women for COVID-19 on admission to hospital.
Although 74.68 \% of respondents strongly agreed or agreed that having
the COVID-19 test had a positive effect on the care provided to both
themselves and their babies, 11.39\% disagreed or strongly disagreed.
Similarly, 69.62\% of the participants either strongly agreed or agreed
that the test had a positive effect on their families with 10.13\%
disagreeing or strongly disagreeing. Post-screening, there was a
significant shift towards women agreeing with the statement that they
would be happy if their maternity units offered screening for COVID-19
to all pregnant women on admission to hospital.

Nulliparous women were significantly more likely to agree that screening
for COVID-19 would have or had a positive effect on their own and their
babies care as compared to multiparous women. Nulliparous women were
also more likely to agree that screening would have or had a positive
effect on their families. There were no other significant associations
between demographical factors and answers to statements.

Table 2 summarises responses to statements in the pre-screening cohort.
Table 3 summarises responses to statements in the post-screening cohort.
Table 4 compares the responses in statements between the pre-screening
and post-screening groups.

\emph{Discussion}

Our results suggest that despite the discomfort from having a swab
taken, screening of the inpatient maternity population is acceptable to
women with generally positive effects on themselves, their babies, and
their families. Nulliparous women are more likely to perceive the
positive impacts of screening on their care, their babies care, and the
impact on their families as compared to multiparous women.

This patient survey also highlighted that there is a high ethnic
diversity, a high number of occupants per house and a low employment
rate amongst our pregnant women, which is consistent with the general
population of Newham borough.\textsuperscript{{[}16{]}} These factors,
in addition to the high population density in the area are likely to be
contributing factors to Newham the highest age-standardised COVID-19
related mortality rate in the UK. \textsuperscript{{[}17{]}}

Universal screening provides the opportunity to use COVID-19 status to
appropriately assign beds and personal protective equipment (PPE),
thereby minimising spread amongst both healthcare staff, patients, and
visitors. This is particularly important in highly populated areas such
as Newham, as overcrowding is a major factor in the transmission of
diseases with epidemic potential.\textsuperscript{{[}18{]}}

There are minimal and diverse data regarding the population prevalence
of asymptomatic pregnant women. Sutton et al, in a study carried out in
New York, identified that 13.7\% of asymptomatic pregnant women tested
positive for COVID-19,\textsuperscript{{[}19{]}} with Vintzileos et al
reporting a similar value of 13\%.\textsuperscript{{[}20{]}} However,
Tassis et al, in a study carried out in Italy, identified that only
0.8\% of asymptomatic pregnant women tested positive for
COVID-19.\textsuperscript{{[}21{]}} These discrepancies arise from the
different prevalence' of COVID-19 depending on the country of study and
the point on the pandemic curve that the study was performed. Since
prevalence cannot be extrapolated from other populations, it is vital
that we continue to perform repeated testing in asymptomatic COVID-19
individuals, in order to effectively guide public health measures aimed
at limiting the reproducibility of the virus and the spread of the
infection. We showed that such a policy would be well accepted by
consumers', which is key in the implementation of new policies.

Strengths of this study include the timely manner with which it was
conducted, during a time-critical period during the ongoing COVID-19
pandemic. Newham Hospital is one of the first maternity hospitals in the
UK to initiate a screening programme for COVID-19 within its maternity
department. Demographics of the population surveyed were similar to the
demographic diversity of the local population.

Limitations of this study include the response rate, which may lead to a
non-response bias. However, the similarity in demographics between the
pre-screening and post-screening cohorts may be evidence against a major
response bias. The post-screening survey was performed by telephone
consultation, therefore may be more prone to response bias. Finally, the
survey design aimed to explore patient's attitudes and acceptability of
universal screening and was therefore not a validated questionnaire.

\emph{Conclusion}

Our study provides evidence that patient acceptability and tolerance to
COVID-19 screening is high, which is key for future implementation of
universal screening across the maternity services in the UK. Universal
testing and targeted social distancing have been suggested by many
academics as an imperative measure to control the pandemic when the
lockdown ends.

Acknowledgements -- Natasha Gupta and Molykuty Dumpakal were also
involved in completing post-screening surveys.

Contribution to authorship: RG, SW, FS and LV designed the
questionnaires. Cluster random sampling of pre-screening questionnaires
was performed by SW, FS and LV. Post-screening surveys were completed by
SW, FS and LV. Results from questionnaires were collected and input into
a database by SW, FS and LV. NS performed the data analysis and wrote
the manuscript. The manuscript was edited by SI, FS and LV.

Disclosure of interests: None

Ethics approval: Not required

Funding: Not applicable

1. Mayo Clinic. \emph{Coronavirus disease 2019 (COVID-19)} . 2020;
Available from:
https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963.

2. Organisation, W.H. \emph{Novel Coronavirus -- China} . 2020;
Available from:
https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/.

3. World Health Organisation. \emph{WHO Director-General's opening
remarks at the media briefing on COVID-19 - 11 March 2020} . 2020;
Available from:
https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.

4. BBC News. \emph{Coronavirus: Two cases confirmed in UK} . 2020;
Available from: https://www.bbc.co.uk/news/health-51325192.

5. Office for National Statistics. \emph{Coronavirus (COVID-19) roundup}
. 2020; Available from:
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19roundup/2020-03-26.

6. UK, G. \emph{Coronavirus (COVID-19): getting tested} . 2020;
Available from:
https://www.gov.uk/guidance/coronavirus-covid-19-getting-tested.

7. Centers for Disease Control and Prevention. \emph{Evidence supporting
transmission of severe acute respiratory syndrome coronavirus 2 while
presymptomatic or asymptomatic} . 2020; Available from:
https://wwwnc.cdc.gov/eid/article/26/7/20-1595\_article.

8. Royal College of Obstetricians and Gynaecologists. \emph{Coronavirus
infection and pregnancy} . 2020; Available from:
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/\#general.

9. Office for National Statistics. \emph{Deaths involving COVID-19 by
local area and socioeconomic deprivation: deaths occurring between 1
March and 17 April 2020} . 2020; Available from:
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand17april.

10. Dietz, C.A., et al., \emph{Patients' attitudes about rapid oral HIV
screening in an urban, free dental clinic.} AIDS Patient Care STDS,
2008. \textbf{22} (3): p. 205-12.

11. Steward, W.T., et al., \emph{HIV-related stigma: adapting a
theoretical framework for use in India.} Soc Sci Med, 2008.\textbf{67}
(8): p. 1225-35.

12. Fowler, N.R., et al., \emph{Older primary care patients' attitudes
and willingness to screen for dementia.} J Aging Res, 2015.\textbf{2015}
: p. 423265.

13. Soneson, E., et al., \emph{Acceptability of screening for mental
health difficulties in primary schools: a survey of UK parents.} BMC
Public Health, 2018. \textbf{18} (1): p. 1404.

14. Walker, C.L., et al., \emph{Acceptability of latent tuberculosis
testing of migrants in a college environment in England.} Public Health,
2018. \textbf{158} : p. 55-60.

15. Centers for Disease Control and Prevention. \emph{Evaluation
Toolkit: Patient and Provider Perspectives about Routine HIV Screening
in Health Care Settings.} 2012; Available from:
http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm.

16. Newham London. \emph{Newham Facts and Figures} . 2020; Available
from: https://www.newham.info/newham-facts-and-figures/.

17. GOV.UK. \emph{Regional ethnic diversity} . 2019; Available from:
https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/regional-ethnic-diversity/latest.

18. World Health Organisation, \emph{What are the health risks related
to overcrowding?} 2020.

19. Royal College of Paediatricians and Child Health. \emph{COVID-19 -
guidance for neonatal settings} . 2020; Available from:
https://www.rcpch.ac.uk/resources/covid-19-guidance-neonatal-settings.

20. Vintzileos, W.S., et al., \emph{Screening all pregnant women
admitted to Labor and Delivery for the virus responsible for
COVID-19.}Am J Obstet Gynecol, 2020.

21. Tassis, B., et al., \emph{Effectiveness of a COVID-19 screening
questionnaire for pregnant women at admission to an obstetric unit in
Milan.} Int J Gynaecol Obstet, 2020.

\textbf{Hosted file}

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\selectlanguage{english}
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