Lifestyle Changes and COVID-19 Related Perceptions of Turkish Healthcare Workers

This study seeks to investigate and understand the perceptions of and lifestyle changes adopted by healthcare workers (HCWs) in Turkey who were on the front line of the fight against the outbreak of COVID-19. A total of 33 female HCWs with bachelor’s degrees were included in the study. In-depth interview techniques were used. The data analysis was performed with MAXQDA 2020 qualitative data analysis package program. The female HCWs perceived COVID-19 as rapidly contagious, deadly, dangerous, and long-term. Their perception as to the cause of the outbreak was akin to conspiracy thoughts such as bioweapon. In addition, the study determined that social media was the preferred medium for getting news because the news given in the traditional media was not trusted. It was seen that the attitude of participants regarding the preventive measures was in line with the recommendations of international organizations. In terms of lifestyle changes, for example, the dietary habits and physical activity levels of all the HCW participants, changed and online environments were used for communication/socialization. Those HCW participants who smoked, stated that smoking increased the risk and severity of COVID-19, and they declared an increase in the amount of their use. Those HCW participants who consumed alcohol, reported that alcohol consumption increased during the period of the outbreak in order to maintain socialization and relaxation. Those HCW participants who did not smoke or drink alcohol mentioned that they did not intend to start. This study contributes to an understanding of the impact on HCWs of significant health events especially in terms of their perceptions of and their lifestyle changes as a result of such health events.


Introduction
COVID-19, a novel coronavirus strain, is associated with acute and severe respiratory illness (Gorbalenya, 2020).The first outbreak of the COVID-19 virus was reported in Wuhan China on 31 December 2019 (Hui, 2020).In the following months, COVID-19 infection spread very rapidly around the world (Wan´kowicz et al., 2020).As the number of deaths from the disease increased worldwide, it turned into a major global health crisis requiring large-scale behavioral change (Bavel et al., 2020).Lockdown, quarantine and isolation to prevent the spread of the disease have caused people to worry and see themselves at risk of catching COVID-19.
In a global pandemic where there are difficulties in the fight against COVID-19, the pandemic perceptions and approaches of healthcare workers can be considered as an important study target group to be examined (Galbraith et al., 2021;T. Xu et al., 2023;M. Xu & Zhang, 2020).As well as the general public, healthcare workers' perceptions of COVID-19 have serious effects on the extent to which public interventions such as vaccination and isolation are conformed to.According to studies there is a positive relationship between risk perception and compliance with interventions to prevent COVID-19 (Deressa et al., 2021;Kayi et al., 2023;Saddik et al., 2022).
However, it has also been shown that the increase in COVID-19 risk perceptions of healthcare workers statistically increased their death anxiety decreased their life satisfaction and psychological well-being (O ¨zer et al., 2023).Moreover, it has been shown that this infection has a particular negative impact on the well-being of healthcare workers (Boamah et al., 2023;Byrne et al., 2023;Chemali et al., 2022;van den Broek et al., 2023;Wan´kowicz et al., 2020).During the COVID-19 pandemic, healthcare workers have been shown to experience many negative conditions such as physical fatigue, anxiety, insomnia, and psychological distress (Diomidous, 2020;Garcı´a-Martı´n et al., 2020;Labrague, 2021;Sagherian et al., 2023).In addition, it is reported that female HCWs perceived more of an emotional impact of COVID-19 compared to male HCWs and that women had a higher risk perception of COVID-19 compared to men (Richards et al., 2023).Healthcare staff working in hospitals were at higher risk of spreading the virus to patients, colleagues, family and friends, so their perceptions and attitudes toward COVID-19 were critical to preventıng the spread of the disease (Buerhaus et al., 2020).
The perception of the risk of COVID-19 has been associated with changing daily routines such as physical and social distancing, personal hygiene, staying at home, and avoiding crowded environments (Kwok et al., 2020;Tekin & Kılıc x, 2023;Yıldırım et al., 2020).This can be explained by people's ability to adapt to new situations when they are at risk of a disease that can lead to serious health problems (Slovic, 1987).Li et al. (2023) conducted a study with adults in 30 countries, covering the World Health Organization (WHO) regions.It was shown that sitting times and screen time increased, social activities were negatively affected, the frequency of cooking and eating at home increased, and alcohol and tobacco use decreased during the pandemic period (Li et al., 2023).
In a study conducted with 1,911 healthcare workers in Singapore between December 2020 and the end of January 2021, aspects of lifestyle, including diet, exercise, sleep duration, smoking, and alcohol intake, were associated with quality of life scores during the COVID-19 outbreak, and a healthy lifestyle was shown to increase the quality of life score (Khaing et al., 2023).In a study conducted with public health nurses, the positive effects of a healthy lifestyle on adaptation and coping were shown in the COVID-19 pandemic (Erika et al., 2023).In another study, health-promoting lifestyle components, including healthy eating, adequate sleep and exercise were shown to positively affect the working requirements of healthcare workers during the COVID-19 pandemic (Chatterjee et al., 2022;Kim et al., 2021;Shakerian et al., 2023;Wright et al., 2021).
Studies on how healthcare workers define and view COVID-19, as well as their lifestyle changes and their potential consequences during the pandemic are valuable resources for public health measures.In particular, such studies provide important findings and recommendations to slow infection rates and prevent persistent psychological risks in special groups, including healthcare workers, who were prone to high morbidity and mortality risk during the COVID-19 pandemic (Pinto et al., 2020).
The HCWs' perceptions and lifestyle modifications in similar situations have strategic importance because HCWs are the primary source of information in the healthcare system and guide patients in their everyday care.From this point of view, this study aims to look at and understand the perception of the disease and the lifestyle changes of healthcare professionals during the COVID-19 period.

Design and participants
The study was designed in line with the descriptive phenomenological pattern, one of the qualitative research designs.An in-depth interview technique was used in the research, and a semi-structured interview form was used.The research target group consisted of female HCWs working in public hospitals in _ Izmir/T€ urkiye.The participants were selected using the purposeful sampling method based on volunteering, years of work experience, and education.The inclusion criteria for the study was determined as follows: being a woman, being a participant in this study, having a bachelor's degree in the field of health (at least 4 years), having worked in the field of health for at least 2 years, working actively in public hospitals and not having a chronic disease.The exclusion criteria of the study was not giving clear and comprehensible answers at an adequate level in the interview, leaving the interview halfway, and interviewing for less than 30 minutes.
Since women have more duties and responsibilities in Turkey's social and cultural system, especially in the household, female HCWs were selected for the study (Bas xak et al., 2013).Consequently, it can be foreseen that the effects of a negative transformation in the perceptions or lifestyles of women within the scope of HCWs have major social effects.
Sample Size:.While the number of samples is determined by power analysis and effect size calculations in quantitative research, there isn't this kind of method in qualitative research such as in-depth interviews.The data collected in this study was acted upon, and the sampling process was continued until data saturation was achieved so that new codes would not emerge in the statements of the participants.
Collecting Data:.As a first step, the research was announced twice a week for 2 months in five different social media groups of which _ Izmir HCWs are members.Appropriate study participants were contacted and appointments were set for the available times of the current participants.In-depth interview technique, which is one of the main data collection tools (Punch, 2016), is used to collect data in the study.Due to the limitation of face-to-face contact during COVID-19, the interviews were conducted via video calls between the dates 01/03/2021 and 25/04/2021 using online communication applications.At the beginning of the interview, consent was obtained after giving information about the study.After questions about demographic characteristics were asked, a semi-structured interview form which was developed examining studies on the subject was used (Akan et al., 2010;C xırakog˘lu, 2011;FAO, 2020;Jayawardena et al., 2020;Jones & Salathe, 2009;Kocaman et al., 2007;Pinto et al., 2020).All the interviews were recorded by an electronic device.The main questions on the form were ''Please talk about what you think about the emergence of the COVID-19 virus and its spread all over the world?'', ''How do you evaluate the danger dimension of the COVID-19 virus?'', ''Could you please explain what you think about the work done to prevent the spread of the COVID-19 virus?'', ''Could you share your views on the news regarding the COVID-19 outbreak?'',''Could you please tell me about the change in your lifestyle during COVID-19?''.Questions such as smoking, alcohol consumption, and physical activity were also on the form and asked during the interview to discuss changes in lifestyle in detail.When expressions of the HCW participants were not intelligible more details were asked with questions such as: ''Can you please explain a little more?''or ''Can you explain exactly what you mean?''.By using probing questions, the researcher guided the interview so that the research goals were achieved.

Data Analysis
Coding:.Coding is the labeling or marking of various aspects of data into meaningful and small pieces (Miles & Huberman, 2016).Two researchers analyzed the interview transcripts and created codes.At this stage, the Cohen Kappa agreement value was calculated as 81.9%.Since this value was among the acceptable values in the literature, the study was considered reliable (Viera & Garrett, 2005).While determining the codes, five codes that could not be agreed upon between the researchers were excluded from the study.After the code creation phase, the categories and themes were created and the data obtained was analyzed with Maxqda 2020 software, which is one of the commonly used software packages for qualitative data analysis.
Trustworthiness:.It is stated that there should be trustworthiness in qualitative research.In the literature, trustworthiness criteria are grouped under four main headings: credibility, dependability, confirmability, and transferability, and these are determined as the gold standard (Guba & Lincoln, 1982).The member checking method was used to ensure the credibility of this study.After the interview, the audio recording was deciphered and a summary of the collected data was sent to the participants, and they were asked to express their thoughts on the accuracy.In addition, the participants had the opportunity to add the points they wanted to add.As well as the Maxqda 2020 software program, the researchers held weekly meetings to share their progress and experiences about the study.For dependability, investigator triangulation, which is one of the triangulation methods, was used.In line with this method, more than one researcher took part in the collection, analysis, and interpretation of the data.Thus, it provided both the confirmation of the findings and different perspectives (Carter et al., 2014).To ensure transferability, the research processes were presented detailed and precisely.In addition, one-to-one quotations were made from the participants.It is known that direct quotations also contribute to the reliability of the research (LeCompte & Goetz, 1982).The references made are indicated with italic emphasis, and the citations are shown with the sequence number given to the participants.Confirmability was ensured by collecting data via two researchers and having each researcher code the data individually.

Strengths and Limitations:
It is thought that this article will contribute to the literature by providing data on the perception and lifestyle changes of Turkish healthcare professionals during the COVID-19 pandemic.An appropriate method was selected for the study.The researchers who conducted the interviews were chosen as they are trained and experienced in conducting interviews.It is thought that conducting the research only with the female gender will better reflect common attitudes and experiences.There was a risk that the interviews could not be conducted in depth due to the use of video interviews using communication applications.To avoid this, the researchers tried to make the interviews more effective by asking further questions and encouraging discourse.The study is based on the verbal reports of the participants.Verbal reports carry potential risks of bias and under/overreporting for social acceptance.To minimize this risk, the anonymity and confidentiality of the participants was guaranteed.In addition, after the interview, the data summary obtained from the voice recording transcripts was sent to the participants and they were asked to express their thoughts.The study is not without some limitations.Since the study was conducted as a qualitative study, the sample size was limited to 30 HCWs and the results could not be generalized.The fact that health workers working in rural areas and private health clinics were not interviewed in the study can also be considered as a limitation.The first day of data collection in this study coincided with the 47th day of the COVID-19 vaccination programme in Turkey (Republic of Turkey Ministry of Health, 2021).Therefore, the study may not reflect the impact of the pandemic before vaccination.However, it is thought that the results of the study will provide useful data for future studies.

Ethical Considerations
At the beginning of the interview, it was declared to all participants that the study was conducted on a voluntary basis and that the participants could withdraw from the study at any time without being subject to any sanction.In addition, the participants were assured about the confidentiality of the information and audio files and the anonymity of the same.In order not to affect the patient care processes and the rest times of the participants, the appointments were arranged according at an appropriate and suitable time.Considering the risk of contamination, which is an important issue in outbreak conditions, the use of paper and pencils was avoided and verbal consent was obtained.The ethical suitability of the study was approved by the decision of the XXXXXXX University Non-Invasive Clinical Research Ethics Committee dated 07.08.2020 and numbered 2020/18-04.

Results
Due to the data saturation point being reached by the 33rd person, the sampling process was stopped and the study sample was formed from 33 people.In the study sample, the information consisted of the age, education, and professions of female HCWs with four questions about the demographic characteristics of the health personnel.Table 1 shows the demographic structures of the research participants that were interviewed.
Perceptions of the COVID-19 Outbreak.Theme 1. Perceptions Related to the Cause of the Disease: According to the interview data, in the relationship map of the participants, the strongest relationship of the cause of the disease perception theme was with the ''bioweapon'' category.In addition, other prominent codes are respectively ''wild animals,'' ''test,'' ''population reduction (or population control),'' ''global warming,'' and ''diet.Figure 1 shows the relationship between categories and codes in the context of Theme 1.The participants, who explained the cause of the disease as a result of a bioweapon, explained mostly the underlying causes as a weapons test, economic reasons, and population reduction possibilities.
P8: ''The theory that the virus from a wet market has spread all over the world doesn't make sense to me.The world's resources are no longer sufficient for the growing population.If this continues, economies will collapse.This disease seems to me like an intervention that came out of a laboratory.''Theme 2. Perception of the Danger of the Disease: It has been observed that ''It spreads quickly'' code about the disease becomes prominent in the findings related to the danger of the disease.Other prominent codes are listed as ''deadly'' and ''dangerous.''Those who see the treatment of the disease as possible believe in the curative effect of the vaccine, while those who do not see it as possible mention that the fight against mutations or new viruses will continue.Those who explain that catching COVID-19 is inevitable, associate this with the fact that the disease is deadly and rapidly transmitted.In addition, the prominent perceptions in the interviews are that the disease will continue through mutations.When the explanations of those, who said that it wasn't possible not to catch COVID-19, are examined, it is seen that they associate the issue with economic reasons (See Figure 2).
P7: This disease is fatal for some individuals yes, but how long will you protect yourself?You can't reduce the risk to zero with a vaccine.We have a virus that constantly mutates and quickly spreads.We do not have a vaccine for every mutation.Will every country be able to afford these vaccines for its citizens?A great uncertainty for all of us.Theme 3. Perception of Preventive Studies: The ''importance of hygiene'' code stands out in almost all of the data on preventive studies related to the COVID-19 outbreak.''protective equipment,'' ''mask requirement,'' ''proper use of mask,'' ''hand hygiene,'' ''disinfectant,'' and ''cleaning'' codes are associated with the ''importance of hygiene'' category.It has been emphasized that the spread of the disease can be prevented by providing protective equipment to healthcare staff (to protect HCWs and avoid transmission from medical personnel to individuals who apply to the hospital), proper use of masks, and hand hygiene training.P1: ''Personal hygiene is very important.In hospitals, we still see people wearing their masks under their chin.We warn, but sometimes we fear.''Theme 4. Perception of the Spread and Continuation of the Outbreak: When the data on the spread and continuation of the COVID-19 outbreak are examined, the code ''the disease will continue for another year'' comes to the fore.However, the codes ''it will continue for at least 2 more years'' and ''it is impossible not to catch the disease'' are also seen as an apparent perception.In addition, as a remarkable point, those who believe in the protective effect of the vaccine state that they believe that the disease will last longer and its spread will not decrease.They attribute these thoughts to people's noncompliance with vaccination programs.Those who do not consider the protection of the vaccine sufficient think that the end of the outbreak is possible only with a positive mutation.
P26: ''I guess we will see at least one year or even two more years because even if we are vaccinated, there is no guarantee that a definite result will be obtained.''P12: ''I think it is impossible not to get sick no matter how much we protect ourselves.''Theme 5. Perception of the News in Media related to the COVID-19 Outbreak: This theme includes the distribution of information in the media and it is emphasized by the participants that the media mostly hides the real information and conveys the news with frightening content.In Figure 3, it is understood that the idea that the media  exaggerates news with frightening content, hides the real information, and produces frightening false content is mostly emphasized.In addition, it is seen that some of those who say that ''the media conveys information honestly'' also talk about horrible content.Some participants mention that the media conveys incomplete information and their news confuses the minds of people.In the context of this theme, when the relationship between categories and codes is examined, it can be thought that there is distrust toward the news in the media.
P19: An atmosphere of fear is created in the news given in the media.Yes, this is not an easy disease, but there is no one who has a seizure in the middle of the road or in the subway, as shown on television in the first days of the outbreak.
Lifestyle Changes.Theme 6. Physical Activity: In the physical activity theme, it was determined that the categories of lockdown, social distance, fatigue, and activity came to the fore.Participants emphasize that they rarely do outdoor activities during the outbreak period and pay attention to social density and distance during activities.''Walking'' and ''cycling'' codes are intense in activities that can be done while maintaining social distance.However, all participants stated that their physical activity has decreased significantly since the beginning of the outbreak.
Decreased physical activity is associated with fatigue, risk of contamination, lockdown, presence of people who do not wear masks, and malaise codes.P4: ''We are not physically active normally, but now we are much more inactive.We just commute to work.''Theme 7. Social Life: The most prominent categories in this theme are social media use, online events and home visits.Social media usage is mostly associated with codes of ''socialization,'' ''getting news,'' ''communication longing,'' and ''passing time.''The primary purpose use of social media has come to the fore as ''interaction with other people.''It was also used to get news because of the distrust of the news obtained in the traditional media.In addition, communication and interaction was ensured in family groups and friend groups, especially in the risk group of patients and elderly family members.Instead of face-to-face events in normal times, the spread and normalization of their virtual versions was mentioned, and the idea that this could be a new era for social life was conveyed.Another category, ''home visits,'' is associated with ''contamination risk'' and ''liability'' codes.Home visits have been reduced due to both the risk of transmitting the disease and the risk of contracting the disease.
P21: ''I have used social media a lot.I am especially curious about the people at home and I try to follow the agenda.Hospital meetings are online.Even my cousin's wedding ceremony was online, it was crazy.''Theme 8. Nutritional Habits: The data on nutritional habits in the outbreak are given in Figure 4.In the light of the data in this figure, positive nutrition categories such as ''increased consumption of fruit, vegetables, and water'' become prominent.However, it is observed that negative nutrition codes such as ''convenience food'' and ''cola'' are included in the nutritional habits of the same people.In the outbreak, the participants mostly emphasized that the number of meals for themselves and their family members increased.Those whose meal habits change positively emphasize ''fruit,'' ''vegetables,'' and ''milk.''Participants denote that the consumption of fruits, vegetables, and water increase in the outbreak.
Concerning the association between nutrition and COVID-19, all participants believe that excellent and right nutrition will boost the immune system, and they advise their family members to eat healthily to protect them from the disease.In addition, it was emphasized in the data that the course of the disease may change with nutrition.However, the general view is that ''there is no miraculous food/nutrient that can protect from the outbreak alone,'' and ''pharmacological supplements are needed.''P26: ''Pre-disease nutrition is important in terms of increasing immunity.It can also harm very healthy people.In the disease process, I think extra supplements will be needed to fight against the virus.'' Participants also report that they have experienced changes in their eating out habits, which is one of their nutritional habits.Participants state that they do not eat out due to concerns such as social distance, hygiene, and sanitation, and they minimize the frequency of ordering meal.
P17: ''We do not eat out anymore; we used to go at least once a week before the outbreak.We have not gone for a long time; we begin to go rarely.''Theme 9. Smoking in the Outbreak: In this theme, there are four main categories such as ''smoking increases the risk of COVID-19,'' ''smoking aggravates the symptoms of COVID19,'' ''I smoke'' and ''I do not smoke.''Under the categories ''Smoking increases the risk of COVID-19" and "Smoking aggravates the symptoms of COVID-19,'' similar codes were created: ''smoking suppresses immunity'' and ''weakens the lungs.''The category ''I smoke'' is strongly associated with the codes ''I have increased the number of cigarettes,'' ''I can't quit'' and ''it is relaxing.''The ''I don't smoke'' category is associated with the ''I never think of smoking'' code.
P5: I smoke.I am aware that it is a risk factor risk for COVID-19, but I can't quit right now.I can even say that the number of cigarettes I smoke daily has increased.It helps me cope with stress.
Theme 10.Alcohol Consumption during the Outbreak: The strongest categories of the alcohol use theme are ''I don't drink alcohol'' and ''I drink alcohol.''In the category of ''I drink alcohol,'' the codes of ''longing for socialization'' and ''reducing stress'' were found to be strongly related both with each other and with the code ''I have increased my use of alcohol.''I don't drink alcohol category is associated with "alcohol is unhealthy,'' ''alcohol suppresses immunity,'' and codes.
P11: My alcohol use has increased compared to before.When you run out of things to do at home, your only life becomes work.You need something that feels normal and relaxing.

Discussion and Conclusions
Governments initially imposed restrictions on outdoor activities and later implemented national quarantine practices according to the size of the COVID-19 pandemic to fight against it on a global scale.Restriction, quarantine, and the high-risk perception stemming from these practices create the danger of physical inactivity and sedentary behavior, and therefore it increases longterm biological and psychological risks (Mattioli & Puviani, 2020).
Perceived risk of COVID-19 disease has an impact on the psychological health and well-being of HCWs (Khoo et al., 2022).In the study comparing anxiety and the perception of control of the COVID-19 pandemic conducted by Ekiz et al. (2020), it is determined that demographic characteristics of people create differences in the perception of the pandemic.They also indicated that people have low perceptions of control over the COVID-19 pandemic.Studies show that the risk perception of the COVID-19 and worry about this pandemic are high among HCWs (Abdel Wahed et al., 2020;Abolfotouh et al., 2020;Batu et al., 2021;Dekeyser et al., 2023;Gorini et al., 2020;Le et al., 2021;O ¨zer et al., 2023;Puci et al., 2020).These studies determined that the perception that the COVID-19 pandemic is long-lasting and that personal hygiene is important in the pandemic process in actively working HCWs.It is observed that female HCWs participating in this study perceive the COVID-19 pandemic as deadly, dangerous, and rapidly transmitted.In addition, it was seen that the participants made statements similar to the recommendations of the World Health Organization, such as the importance of hygiene in measures to prevent the disease, hand hygiene, and the need for masks (WHO, 2020).
It is seen that conspiracy thoughts emerge during pandemics.The claim that HIV is a biological weapon developed to kill black people is among the most prominent conspiracy theories (Nattrass, 2013).Similar speculations occurred during the Zika virus outbreak (2015-2016).There have been allegations that governments deliberately spread the Zika virus and to try to reduce the population (Venkatraman et al., 2017).Two of the most prominent conspiracy beliefs during the COVID-19 pandemic period was that the virus is not different from the flu virus and is exaggerated, and the other belief was that it is a deliberately developed bioweapon as part of a population reduction effort (Andersen et al., 2020).In the results of this study, there is a strong relationship between the theme of the perception of the cause of the disease and the category of bioweapons.Surprisingly, the participating HCWs rely on conspiracy theories rather than official statements and scientific data.Quantitative studies on the attitudes of HCW participants towards official and scientific resources and the reasons for distrust, if any, are considered a subject worth investigating.
Social media is very valuable in the modern world (Wilder-Smith & Freedman, 2020).However, it is known that social media can be a dangerous way to inform (Al-Rabiaah et al., 2020).Kouzy et al. (2020) on Feb 27, 2020, reviewed 617 English posts on a social network after excluding those with humorous or non-serious content.They showed that 24.8% of the posts contained false information and 17.3% had unverified information.Research from Italy showed that between Dec 31, 2019, and April 30, 2020, fake news was shared over 2 million times (23% of total shares) (Moscadelli et al., 2020).A study in India showed that while social media was the second highest source of information for 78.3% of the general public, (Parikh et al., 2020).A study of student nurses reported that participants said that false information and news about the COVID-19 are common on social networks (Lovric´et al., 2020).Akkus x et al. (2022) reported that traditional media and social media were the two main sources of information in a qualitative study conducted with nurse participants.They also reported that social media groups were used as an important communication tool during the pandemic.According to the data of this study, it is seen that the participants received the news from social media due to a distrust of traditional media.This result was interpreted as regrettable as social media is prone to fake news and occasionally stoked anxiety with fake news reports (Rocha et al., 2023).
In a study conducted in the United States, it was reported that life-style changes due to the pandemic were associated with age and higher in women than men (Birditt et al., 2021).Web-based socialization has been shown to become widespread among older adults since the start of the pandemic (Haase et al., 2021).In this study, it was shown that communication and interaction was guaranteed especially in the risk group of patients and elderly family members by web-based tools instead of face-to-face meetings because of the risk of contamination.The measures taken to prevent the spread of the virus during the COVID-19 pandemic have led to the increase and spread of online meetings and events.It is highlighted that information is transmitted via communication technologies during the COVID-19 outbreak and therefore, it is obtained through online platforms among HCWs (Karanfilog˘lu & Sag˘lam, 2021).During the COVID-19 pandemic, the effects on society were tried to be minimized by using the distance education alternative, with online meeting applications instead of face-to-face learning (Pratama et al., 2020).Also, many events have been implemented in online versions.For example, online chess has become much more popular in the process.An increasing number of online chess tournaments with substantial prize money are being held (Bilen & Matros, 2021).In this study, one of the main categories of the social life theme is online events and activities.
The Food and Agriculture Organization of the United Nations (FAO, 2020) mentions that no food or dietary supplement can independently prevent the COVID-19 pandemic.However, they emphasize that a healthy diet is a vital component of a strong immune system.During the outbreak period, it is suggested to establish and maintain a well balanced diet with high amounts of minerals, antioxidants, and vitamins (Clemente-Sua´rez et al., 2021;de Faria Coelho-Ravagnani et al., 2021;Muscogiuri et al., 2020).According to the findings, the perceptions of participants agree with this view.According to the data, it is highlighted that a healthy diet may have positive effects to protect people from the virus; however, any special food does not have protective properties purely.It is observed in the pandemic that the number of meals of the participants and their families increased, as well as convenience food, fruit/vegetable, milk, cola, and water consumption, while their eating out habits decreased.Also, the most prominent code is about the increase in the amount of daily water intake.In light of these explanations, it can be said that the HCW participants changed eating and drinking habits during the pandemic.
In a study conducted with HCWs participants stated that the most important factor that changed their lifestyle was the increase in sleep duration, and there was no change in food choices (Abdulah et al., 2022).A study conducted with adults in Ghana showed that participants made healthy lifestyle efforts to prevent COVID 19 and its complications, maintaining/increasing physical activity, vegetable and fruit consumption, and avoiding alcohol and junk food consumption (Saah et al., 2021).In a cross-sectional study of HCWs in Singapore during reported that lockdown, vegetable intake decreased, while consumption of prepared and ready-to-eat foods and alcoholic beverages increased (Huang et al., 2022).A study conducted in Turkey showed that dietary habits of HCWs during the pandemic were affected by perceived stress, emotional eating, economic concerns, and concerns about water and food security.In addition, losing a loved one due to COVID-19 has been identified as an independent risk factor (Yaman & Hocaog˘lu, 2023).
In particular, the increase in physical inactivity and sedentary behavior due to social isolation rules is considered a second pandemic and it is estimated that it may worsen and continue after the pandemic (Hall et al., 2021).The most obvious recommendation against this danger was that exercises done at home were significant to protect mental and physical health in quarantine (Lippi et al., 2020).Apart from the lack of background around this recommendation, it can be said that there is a lack of information regarding the physical and social activities of HCWs.Some of the responses also touched on these aspects in the findings of this study.In this study, participants emphasized that they rarely did outdoor activities during the outbreak period and infrequently pay attention to social density and distance during activities.However, all participants stated that their physical activity has decreased significantly since the beginning of the outbreak, and decreased physical activity is associated with fatigue, risk of contamination, lockdown, presence of people who do not wear masks, and malaise.Similarly, a longitudinal study in Iran which examinated the impact of COVID-19 pandemic on physical activity levels among HCWs showed that physical activity decreased compared to the pre-outbreak period (Zare et al., 2023).
In a meta-analysis study conducted by Reddy et al. (2021), it is underlined that smoking is associated with the critical progression of the COVID-19 infection, hospital mortality, and the need for mechanical ventilation.It is found that smoking behavior has not changed or has increased during the pandemic, and this was explained as ''excessive stress caused by the pandemic increases smoking,'' considering the relationship between negative affectivity and smoking (Klemperer et al., 2021).In a study conducted with primary HCWs found that high level distress was associated with smoking (Abdu et al., 2023).It has been shown that the number of daily cigarettes smoked is higher in HCWs with burnout and who are exposed to a high physical and mental load during COVID-19 (Al-Otaibi et al., 2023;Ziedi et al., 2023).
The studies from the early period of the outbreak report that alcohol consumption increased at different rates during the COVID-19 pandemic (Avery et al., 2020;Koopmann et al., 2020).In a study conducted in Australia, it is determined that alcohol consumption increased during the COVID-19 pandemic and the increase in consumption by women is higher than that of men (Biddle et al., 2020).It is concluded that people with low education levels and people with higher levels of stress due to restrictions are at higher risk of consuming alcohol during periods of social restriction (Koopmann et al., 2020).Vanderbruggen et al. (2020) inform in their study that more alcohol is consumed during the COVID-19 pandemic.
There are studies showing that alcohol consumption is effected by various factors such as loneliness, boredom etc. during the COVID-19 outbreak (Bragard et al., 2022;Cedrone et al., 2022;Danckert, 2022;Killgore et al., 2021).For instance Karram et al. (2023) reported in their qualitative research that HCWs used alcohol to reduce stress quickly and effectively.
The World Health Organization (WHO, 2020) reported that alcohol consumption particularly makes people more vulnerable to the COVID-19.It is recommended that alcohol consumption should be minimized during the COVID-19 pandemic, as it compromises the immune system and creates negative consequences (WHO, 2020).In addition to its biological effects, excessive alcohol consumption can also lead to significant psychological problems such as anxiety and depression in the COVID-19 pandemic (Pollard et al., 2020).In this study, the participants mentioned that smoking increases the risk of the COVID-19 and aggravates the symptoms of the COVID-19.They explained these effects as smoking suppresses immunity and weakens the lungs.Further, the participants who smoked stated that they had increased the number of cigarettes, could not quit and that smoking cigarettes was relaxing.Similarly, the participants who drank alcohol regularly stated that they increased their use of alcohol and they explained that drinking alcohol helped with f stress reduction and longing for socialization.During the COVID-19 pandemic, healthcare workers have been shown to be affected in different contexts such as individual, interpersonal, institutional, social and political (Chemali et al., 2022).It is stated that in this period mental wellbeing of HCWs was affected and certain experiences can have devastating effects on both the personal and professional lives of healthcare workers (Boamah et al., 2023;Byrne et al., 2023;Chemali et al., 2022;van den Broek et al., 2023).From this point of view, the fact that HCWs increase alcohol and cigarette use for relaxation and socialization is a finding that should be emphasized.

Implications
Female healthcare workers who participated in the study perceive COVID-19 as rapidly contagious, deadly, dangerous, and long-lasting.When the perception of the cause of the outbreak was examined, it was seen that expressions compatible with conspiracy thoughts such as biological weapons came to the fore, contrary to official and scientific explanations.In addition, it has been determined that social media is preferred to get news because the news given by traditional media is not trusted.This state of distrust was strongly associated with statements such as the media hiding real information, being exaggerated, and being scary.Large-sample and well-planned studies examining the attitudes of healthcare professionals towards official and scientific statements in the news sources that they use would be useful.It is thought that it may be useful to increase resistance to an infodemic in similar situations by providing health literacy training to healthcare professionals.In addition, studies to increase the reliability of official sources may contribute to the acceptance and dissemination of accurate and reliable information and prevent the confusion created by conspiracy theories.Since healthcare professionals are seen as opinion leaders in society on health, this issue can be considered as an important issue in terms of public health.It was observed that the attitudes of the participants regarding protective measures were in line with the recommendations of international organizations.Participants stated the importance of nutrition during the pandemic at similar points with WHO and FAO.It can be said that the information methods applied for this participant group were effective and efficient in these subjects.It was determined that physical activity of all participants decreased and online environments were used for communication/socializing.This situation indicates that the recommended isolation rules were followed.Although HCWs who smoke stated that smoking increases the risk and severity of the disease against COVID-19, they declared an increase in the amount of use.It is noteworthy that tobacco use increased in some participants even at such a serious risk of illness.Specialized efforts to reduce tobacco use in HCWs regardless of the pandemic may be useful.On the other hand, alcohol users did not mention the negative effects of alcohol, but reported that alcohol consumption continued to increase compared to the pre-pandemic period in order to maintain socialization and relaxation.Therefore, providing psycho-social support to healthcare professionals in similar situations may be considered beneficial.The attitudes and behaviors of HCWs, who are opinion leaders in major health incidents affecting large masses, are important.For this reason, institutions informing HCWs regularly on all basic issues related to diseases like COVID-19 can contribute to the dissemination of correct information in society.

Conclusion
In conclusion, it was observed that the participating HCWs perceived COVID-19 as very dangerous and changed their lifestyle accordingly during the outbreak.Female healthcare workers perceived COVID-19 as highly contagious, deadly, and long-lasting.The perception of the cause of the outbreak was seen as parallel with conspiracy theories.Additionally, it was determined that social media was preferred for getting news.The attitude of participants regarding preventive measures was in line with the recommendations of international organizations.The dietary habits and physical activity of all participants changed and online environments were used for communication and/or socialization.Smoker and alcohol user participants declared an increase in usage.It is suggested that HCWs should be further examined/considered in respect of their lifestyle changes and perceptions in those health incidents that have a significant impact on society.

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

Figure 2 .
Figure 2. The danger of the disease.

Figure 4 .
Figure 4. Nutritional habits in the outbreak.

Table 1 .
Sociodemographic Information of the Participants.
Figure 1.Perception of the cause of the disease.