Hrev_master Abstract Nutritional status and health are crucial factors in maintaining a healthy pregnancy, especially during the COVID-19 pandemic. This study aimed to analyze the relationship between CGOL (Chlorophyll, Ginger, Orange, and Lemongrass) consumption and confirmed COVID-19 cases in pregnant women. The research, conducted in East Java with 250 purposively sampled respondents, employed a correlational cross-sectional design. Data were collect- ed through questionnaires, Likert scales, and documentation. Analysis of research data using descriptive analysis and Spearman- Rho analyses. The study revealed that CGOL consumption in preg- nant women was 28% less than optimal, 21.2% moderate and 50.8% optimal. Confirmed COVID-19 cases in pregnant women are 10%, and 90% are not confirmed. There was a significant rela- tionship between CGOL consumption and confirmation of COVID-19 in pregnant women (p=0.0001). These findings empha- size the importance of integrating CGOL-based nutritional guide- lines into prenatal care programs, particularly during pandemics, to enhance pregnant women’s and their babies’ health. Introduction Pregnancy is a significant event for both pregnant women and their partners,1 representing a period of maturation amidst potential crises.2 Physiological changes during pregnancy lead to a decrease in immunity,3 necessitating various measures to safeguard the health of expectant mothers.4,5 The global occurrence of COVID- 19, including Indonesia, has presented a critical issue, as there is currently no specific cure for this virus.6 Thus, it is imperative to adopt preventive measures against COVID-19 exposure and infec- tion.7 These preventive measures include physical distancing,8 fre- quent handwashing,9 optimizing nutrition through a balanced diet,10 and the supplementation of essential nutrients to enhance immunity,11,12 Based on health service data from confirmed COVID-19 cases, it is evident that certain demographics, such as the elderly, toddlers, individuals with comorbidities, and pregnant women, are at a higher risk for adverse outcomes.13 Certain nutrients are believed to have immunity-boosting prop- erties, such as foods rich in chlorophyll,14 essential ingredients from spices like ginger and lemongrass,13,15 as well as fruits abundant in vitamin C, such as oranges.11,16 However, no studies have investi- gated whether the consumption of these ingredients effectively enhances immunity in pregnant women, particularly in preventing COVID-19 exposure. Indonesia reported its first two positive cases of COVID-19 on March 2, 2020. By April 15, 2020, the virus had spread to all 34 provinces.17 Jember Regency in East Java, which reported one of the highest Maternal Mortality Rates (MMR) in the province and ranked second in Infant Mortality Rate (IMR), was significantly affected.18 In 2020, there were 645 reported cases of COVID-19 in pregnant women in Indonesia by September 11, 2020.19 Given these circumstances, it is essential to optimize pro- motive and preventive actions to mitigate the risk of COVID-19 Healthcare in Low-resource Settings 2023; volume 11:11749 Relationship between CGOL (Chlorophyll, Ginger, Orange, and Lemongrass) consumption and confirmed COVID-19 cases on pregnant women Diyan Indriyani,1,2 Esti Yunitasari,3 Ferry Efendi3 1Doctoral Nursing Program, Faculty of Nursing, Universitas Airlangga, Surabaya; 2Faculty of Health Sciences, Universitas Muhammadiyah Jember, Jember; 3Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Correspondence: Diyan Indriyani, Doctoral Nursing Program, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. E-mail: diyanindriyani@unmuhjember.ac.id Key words: CGOL; COVID-19; pregnant woman. Contributions: DI Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft, Review & Editing; EY Conceptualization, Investigation, Methodology, Validation, and Writing – Original Draft, Review & Editing; FE Conceptualization, Methodology, Formal Analysis, Validation, and Writing – Original Draft, Review & Editing, Resources, Supervision, and Writing Investigation. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the ethical standards of the University of Muhammadiyah Jember (ethic Number: 0075/KEPK/FIKES/I/2021). During the research, the researcher pays attention to the ethical prin- ciples of information to consent, respect for human rights, benefi- cence, and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 11 September 2023. Accepted: 9 October 2023. Early access: 13 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11749 doi:10.4081/hls.2023.11749 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 16] [Healthcare in Low-resource Settings 2023; 11:11749] Non -co mmerc ial us e o nly complications during pregnancy. While previous research has investigated the nutritional content of chlorophyll,14 ginger, oranges,13 and lemongrass,11 no studies have explored whether the consumption of these nutrients, particularly among pregnant women, can effectively prevent COVID-19 exposure. The aim of this study was to analyzing relationship between CGOL consump- tion and confirmed COVID-19 cases on pregnant women. Materials and Methods Research design A correlational design with a cross-sectional, retrospective study approach was employed, with the research aim of analyzing relationship between CGOL consumption and confirmed COVID- 19 cases on pregnant women. Study participants The study population consisted of pregnant women who received antenatal care at the hospital in East Java in 2020, there were five hospitals as research locations located in East Java province. Researchers determined the sample size 250 samples using purposive sampling techniques from January to July 2021. The inclusion criteria comprised pregnant women who received antenatal care at an East Java hospital, who were willing to partic- ipate as respondents, and who did not have comorbidities. Pregnant women with malnutrition and anemia were excluded. Demographics Key demographic characteristics of the pregnant women included maternal and paternal age (categorized as < 20 years, 20- 35 years, and > 35 years), maternal and paternal education (cate- gorized as elementary-junior high, senior high, and bachelor’s degree), maternal and paternal occupation (categorized as private employees, entrepreneurs, and civil servants), parity status (cate- gorized as primigravida, multigravida, and grandemultigravida), antenatal care visits (categorized as non-routine and routine), fam- ily monthly income (categorized as <2,000,000 IDR, 2,000,000- 5,000,000 IDR, > 5,000,000-7,000,000 IDR, and > 7,000,000 IDR), and the role of health workers and family (categorized as less optimal and optimal). Research instrument Data on the characteristics of pregnant women were collected using a questionnaire that included information on maternal age, paternal age, parity, maternal education, paternal education, mater- nal employment, paternal employment, family monthly income, and antenatal care visits. The role of health workers was assessed using 20 questions, family roles with 20 questions and CGOL con- sumption with 20 questions. The Likert scale was employed to measure responses, offering four choices: always, often, rarely, and never. COVID-19 confirmation data were obtained from patient medical records at both hospitals. Statistical analysis Statistical analysis encompassed univariate and bivariate tech- niques. Univariate analysis was used to describe the categorical characteristics of respondents by providing frequency distribu- tions. Bivariate analysis aimed to explore the relationship between CGOL consumption and confirmed COVID-19 cases on pregnant women with Spearman Rho analyses were utilized with a signifi- cance level set at 5% (0.05). Results The characteristics of pregnant women can be found in Table 1, which includes a total of 250 respondents. It can be inferred that the majority of mothers are aged 20-35 years, with a total of 160 respondents (64%). Most fathers are aged 20-40 years, with a total of 147 respondents (58.8%). The majority of parity status is multi- parous, with a total of 166 respondents (66.4%). For mothers’ edu- cation, most have completed senior high school, with 132 respon- dents (52.8%), and fathers’ education also predominantly falls under the senior high school category, with 168 respondents (67.2%). Regarding occupation, the majority of mothers were housewife with 110 respondents (44%), and the smallest category is Civil Servants, with only 25 respondents (10%). Fathers mostly work as entrepreneurs, with 153 respondents (61.2%). The highest family income within a month falls between IDR 2,000,000 - IDR 5,000,000 or equal to 130.55 USD - 326.37 USD, with 115 respon- dents (46%). Antenatal care visits, as seen in Table 1, are mostly done routine, with 187 respondents (74.8%), and non-routine by 63 respondents (25.2%). Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Frequency distribution of general characteristics of preg- nant women (n = 250). Variable Quantity Percentage Mothers’ age <20 years old 35 14.0 20-35 years old 160 64.0 >35 years old 55 22.0 Fathers’ age <20 years old 8 3.2 20-40 years old 147 58.8 >40 years old 95 38.0 Parity status Primigravida 75 30.0 Multigravida 166 66.4 Grandemultigravida 9 3.6 Mothers’ education Elementary-junior high school 88 35.2 Senior high school 132 52.8 University level 30 12.0 Fathers’ education Elementary-junior high school 43 17.2 Senior high school 168 67.2 University level 39 15.6 Mothers’ occupation Housewife 110 44.0 Private employees 57 22.8 Entrepreneur 58 23.2 Civil servants 25 10.0 Fathers’ cccupation Private employees 70 28.0 Entrepreneur 153 61.2 Civil servants 27 10.8 Family income within a month (IDR/ USD) < 2.000.000 / > 130.55 75 30.0 2.000.000-5.000.000 / 130.55-326.37 115 46.0 > 5.000.000-7.500.000 / >326.37-489.56 35 14.0 > 7.500.000/ > 489.56 25 10.0 Antenatal Care Visit Non-routine 63 25.2 Routine 187 74.8 [Healthcare in Low-resource Settings 2023; 11:11749] [page 17] Non -co mmerc ial us e o nly Data on the role of health workers, family, CGOL consumption and confirmed cases of COVID-19 on pregnant woman are shown in Table 2. The role of health workers and family in pregnant women are mostly optimal, with 175 respondents (70%) and 162 respondents (64.8%), respectively. The majority of CGOL con- sumption is optimal, with 127 respondents (50.8%). Most pregnant women have never been confirmed positive for COVID-19, with 225 respondents (90%). Bivariate analysis was carried out using Spearman Rho as shown in Table 3. There is a relationship between CGOL consumption and confirmed COVID-19 cases with a p value of 0.0001, with a correlation coefficient of 0.647, which means there is a strong relationship. Discussion One of the key strategies for maintaining the health of pregnant women is optimizing their nutrition. The nutritional needs of preg- nant women, both for the mother and the fetus, are critical.12,20 Previous research has suggested that the consumption of foods rich in certain ingredients, such as green vegetables, vitamin C-rich oranges, ginger, and lemongrass, can effectively boost immuni- ty.21,22 Our results indicate that the roles of health workers and fam- ilies in preventing COVID-19 and illnesses in pregnant women were largely optimal. Families play a crucial role in providing essential support to pregnant women during the perinatal period, which includes pregnancy, childbirth, and the postpartum period. Their active involvement is facilitated by daily interactions and a strong sense of responsibility for the well-being of pregnant women.20,23 This family support is vital for preparing pregnant women mentally and emotionally to adapt to the challenges of pregnancy.3,24 Additionally, our findings suggest that the role of health work- ers was predominantly optimal, with a focus on education and health promotion, often provided during antenatal care visits. Timely initiation of antenatal care is influenced by various factors, including maternal age, education level, and socioeconomic status.1 Non-routine attendance, often related to delayed first visits, can pose risks to maternal and fetal health.2 Also stated that both rural and suburban women had a high percentage of a late first ANC visit.2 These findings align with the impact of the COVID-19 pandemic on the mental health of pregnant women, as it has added stress and uncertainty to an already challenging period.25,26 In terms of nutritional behavior, the majority of pregnant women exhibited optimal consumption of CGOL-rich foods. This suggests that many pregnant women include CGOL in their diets, which can be considered a safe and healthy practice.27 These foods, such as green vegetables with chlorophyll, ginger with its numer- ous health benefits,15,28,29 vitamin C-rich oranges, and lemongrass containing essential oils and other nutrients, contribute to overall well-being.16,21,22 The antioxidant and anti-inflammatory properties of gingerol compounds in ginger, for example, can positively impact health.30,31,32 Regarding specific health variables, 90% of the respondents tested negative for COVID-19, while 10% confirmed positive cases. This highlights the susceptibility of pregnant women to res- piratory infections, including COVID-19, due to physiological changes and weakened immunity during pregnancy.4,6 However, it is important to address the stress and mental health challenges that pregnant women face during the pandemic to protect their well- being. Factors such as maternal age, education level, and socioeco- nomic status can influence health behaviors and outcomes. Additionally, maintaining optimal health behaviors during preg- nancy positively impacts overall health, especially during the pan- demic.31,33,34,35 A study indicated that pregnant women are more susceptible to contracting COVID-19 due to potential weakening of their immune systems.9 COVID-19 is characterized by immune- related factors such as reduced lymphocyte levels and elevated proinflammatory cytokines.36 Pregnant women and their fetuses represent a high-risk population during infectious disease out- breaks.36 Furthermore, pregnancies complicated by SARS-CoV-2 infection are associated with an increased likelihood of cesarean delivery and preterm birth.10 The emergence of new mutations in the coronavirus presents unique challenges to the medical commu- nity, as the optimal treatment approach has not yet been deter- mined and often relies on institutional guidelines.37 Several previous studies have explored the relationship between the consumption of nutrients containing CGOL and pre- ventive efforts against COVID-19 in pregnant women. These stud- ies have emphasized the importance of a balanced diet or nutrition- al therapy as a powerful strategy to combat COVID-19.14 Research findings have indicated that around 10.5% of the population, equivalent to approximately 4.6 million adults in South Korea, falls into the high-risk category, with about 20% of them having inadequate intakes of vitamins A, B1, B2, B3, and C.11 While good nutrition, in general, is crucial for recovery from COVID-19 and other serious infections, specific nutrients can be particularly ben- eficial.13 Other studies have suggested that better nutrition and sup- plementation with various nutrients, such as omega-3 fatty acids, amino acids, zinc, and vitamins C and E, may be helpful in pre- venting and treating COVID-19 and other serious infections.16 In line with the aforementioned explanations, vitamin C plays a crucial role in enhancing the body’s immunity, which includes protection against COVID-19.22 Oranges are an excellent example of a fruit rich in vitamin C. Furthermore, the consumption of nutri- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. Frequency distribution of the role of health workers and family, CGOL consumption, and case of COVID-19 on pregnant women (n=250). Variable Quantity Percentage The role of health workers Less optimal 75 30.0 Optimal 175 70.0 The role of family Less optimal 88 35.2 Optimal 162 64.8 CGOL consumption Less optimal 70 28.0 Average 53 21.2 Optimal 127 50.8 Confirmed COVID-19 cases Confirmed 25 10.0 Not confirmed 225 90.0 Table 3. Bivariate analysis of the relationship between CGOL con- sumption and confirmed COVID-19 cases on pregnant women (n=250). Variable Correlation coeficient p-value CGOL Consumption Confirmed COVID-19 Case 0.647** 0.0001 (**) strong relationship. 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