• Research article
  • Open access
  • Published: 04 June 2021

Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews

  • Israel Júnior Borges do Nascimento 1 , 2 ,
  • Dónal P. O’Mathúna 3 , 4 ,
  • Thilo Caspar von Groote 5 ,
  • Hebatullah Mohamed Abdulazeem 6 ,
  • Ishanka Weerasekara 7 , 8 ,
  • Ana Marusic 9 ,
  • Livia Puljak   ORCID: orcid.org/0000-0002-8467-6061 10 ,
  • Vinicius Tassoni Civile 11 ,
  • Irena Zakarija-Grkovic 9 ,
  • Tina Poklepovic Pericic 9 ,
  • Alvaro Nagib Atallah 11 ,
  • Santino Filoso 12 ,
  • Nicola Luigi Bragazzi 13 &
  • Milena Soriano Marcolino 1

On behalf of the International Network of Coronavirus Disease 2019 (InterNetCOVID-19)

BMC Infectious Diseases volume  21 , Article number:  525 ( 2021 ) Cite this article

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Navigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Nine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of Sciences, PDQ-Evidence, WHO’s Global Research, LILACS, and Epistemonikos) were searched from December 1, 2019, to March 24, 2020. Systematic reviews analyzing primary studies of COVID-19 were included. Two authors independently undertook screening, selection, extraction (data on clinical symptoms, prevalence, pharmacological and non-pharmacological interventions, diagnostic test assessment, laboratory, and radiological findings), and quality assessment (AMSTAR 2). A meta-analysis was performed of the prevalence of clinical outcomes.

Eighteen systematic reviews were included; one was empty (did not identify any relevant study). Using AMSTAR 2, confidence in the results of all 18 reviews was rated as “critically low”. Identified symptoms of COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%) and gastrointestinal complaints (5–9%). Severe symptoms were more common in men. Elevated C-reactive protein and lactate dehydrogenase, and slightly elevated aspartate and alanine aminotransferase, were commonly described. Thrombocytopenia and elevated levels of procalcitonin and cardiac troponin I were associated with severe disease. A frequent finding on chest imaging was uni- or bilateral multilobar ground-glass opacity. A single review investigated the impact of medication (chloroquine) but found no verifiable clinical data. All-cause mortality ranged from 0.3 to 13.9%.

Conclusions

In this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic were of questionable usefulness. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards.

Peer Review reports

The spread of the “Severe Acute Respiratory Coronavirus 2” (SARS-CoV-2), the causal agent of COVID-19, was characterized as a pandemic by the World Health Organization (WHO) in March 2020 and has triggered an international public health emergency [ 1 ]. The numbers of confirmed cases and deaths due to COVID-19 are rapidly escalating, counting in millions [ 2 ], causing massive economic strain, and escalating healthcare and public health expenses [ 3 , 4 ].

The research community has responded by publishing an impressive number of scientific reports related to COVID-19. The world was alerted to the new disease at the beginning of 2020 [ 1 ], and by mid-March 2020, more than 2000 articles had been published on COVID-19 in scholarly journals, with 25% of them containing original data [ 5 ]. The living map of COVID-19 evidence, curated by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), contained more than 40,000 records by February 2021 [ 6 ]. More than 100,000 records on PubMed were labeled as “SARS-CoV-2 literature, sequence, and clinical content” by February 2021 [ 7 ].

Due to publication speed, the research community has voiced concerns regarding the quality and reproducibility of evidence produced during the COVID-19 pandemic, warning of the potential damaging approach of “publish first, retract later” [ 8 ]. It appears that these concerns are not unfounded, as it has been reported that COVID-19 articles were overrepresented in the pool of retracted articles in 2020 [ 9 ]. These concerns about inadequate evidence are of major importance because they can lead to poor clinical practice and inappropriate policies [ 10 ].

Systematic reviews are a cornerstone of today’s evidence-informed decision-making. By synthesizing all relevant evidence regarding a particular topic, systematic reviews reflect the current scientific knowledge. Systematic reviews are considered to be at the highest level in the hierarchy of evidence and should be used to make informed decisions. However, with high numbers of systematic reviews of different scope and methodological quality being published, overviews of multiple systematic reviews that assess their methodological quality are essential [ 11 , 12 , 13 ]. An overview of systematic reviews helps identify and organize the literature and highlights areas of priority in decision-making.

In this overview of systematic reviews, we aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Methodology

Research question.

This overview’s primary objective was to summarize and critically appraise systematic reviews that assessed any type of primary clinical data from patients infected with SARS-CoV-2. Our research question was purposefully broad because we wanted to analyze as many systematic reviews as possible that were available early following the COVID-19 outbreak.

Study design

We conducted an overview of systematic reviews. The idea for this overview originated in a protocol for a systematic review submitted to PROSPERO (CRD42020170623), which indicated a plan to conduct an overview.

Overviews of systematic reviews use explicit and systematic methods for searching and identifying multiple systematic reviews addressing related research questions in the same field to extract and analyze evidence across important outcomes. Overviews of systematic reviews are in principle similar to systematic reviews of interventions, but the unit of analysis is a systematic review [ 14 , 15 , 16 ].

We used the overview methodology instead of other evidence synthesis methods to allow us to collate and appraise multiple systematic reviews on this topic, and to extract and analyze their results across relevant topics [ 17 ]. The overview and meta-analysis of systematic reviews allowed us to investigate the methodological quality of included studies, summarize results, and identify specific areas of available or limited evidence, thereby strengthening the current understanding of this novel disease and guiding future research [ 13 ].

A reporting guideline for overviews of reviews is currently under development, i.e., Preferred Reporting Items for Overviews of Reviews (PRIOR) [ 18 ]. As the PRIOR checklist is still not published, this study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement [ 19 ]. The methodology used in this review was adapted from the Cochrane Handbook for Systematic Reviews of Interventions and also followed established methodological considerations for analyzing existing systematic reviews [ 14 ].

Approval of a research ethics committee was not necessary as the study analyzed only publicly available articles.

Eligibility criteria

Systematic reviews were included if they analyzed primary data from patients infected with SARS-CoV-2 as confirmed by RT-PCR or another pre-specified diagnostic technique. Eligible reviews covered all topics related to COVID-19 including, but not limited to, those that reported clinical symptoms, diagnostic methods, therapeutic interventions, laboratory findings, or radiological results. Both full manuscripts and abbreviated versions, such as letters, were eligible.

No restrictions were imposed on the design of the primary studies included within the systematic reviews, the last search date, whether the review included meta-analyses or language. Reviews related to SARS-CoV-2 and other coronaviruses were eligible, but from those reviews, we analyzed only data related to SARS-CoV-2.

No consensus definition exists for a systematic review [ 20 ], and debates continue about the defining characteristics of a systematic review [ 21 ]. Cochrane’s guidance for overviews of reviews recommends setting pre-established criteria for making decisions around inclusion [ 14 ]. That is supported by a recent scoping review about guidance for overviews of systematic reviews [ 22 ].

Thus, for this study, we defined a systematic review as a research report which searched for primary research studies on a specific topic using an explicit search strategy, had a detailed description of the methods with explicit inclusion criteria provided, and provided a summary of the included studies either in narrative or quantitative format (such as a meta-analysis). Cochrane and non-Cochrane systematic reviews were considered eligible for inclusion, with or without meta-analysis, and regardless of the study design, language restriction and methodology of the included primary studies. To be eligible for inclusion, reviews had to be clearly analyzing data related to SARS-CoV-2 (associated or not with other viruses). We excluded narrative reviews without those characteristics as these are less likely to be replicable and are more prone to bias.

Scoping reviews and rapid reviews were eligible for inclusion in this overview if they met our pre-defined inclusion criteria noted above. We included reviews that addressed SARS-CoV-2 and other coronaviruses if they reported separate data regarding SARS-CoV-2.

Information sources

Nine databases were searched for eligible records published between December 1, 2019, and March 24, 2020: Cochrane Database of Systematic Reviews via Cochrane Library, PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Sciences, LILACS (Latin American and Caribbean Health Sciences Literature), PDQ-Evidence, WHO’s Global Research on Coronavirus Disease (COVID-19), and Epistemonikos.

The comprehensive search strategy for each database is provided in Additional file 1 and was designed and conducted in collaboration with an information specialist. All retrieved records were primarily processed in EndNote, where duplicates were removed, and records were then imported into the Covidence platform [ 23 ]. In addition to database searches, we screened reference lists of reviews included after screening records retrieved via databases.

Study selection

All searches, screening of titles and abstracts, and record selection, were performed independently by two investigators using the Covidence platform [ 23 ]. Articles deemed potentially eligible were retrieved for full-text screening carried out independently by two investigators. Discrepancies at all stages were resolved by consensus. During the screening, records published in languages other than English were translated by a native/fluent speaker.

Data collection process

We custom designed a data extraction table for this study, which was piloted by two authors independently. Data extraction was performed independently by two authors. Conflicts were resolved by consensus or by consulting a third researcher.

We extracted the following data: article identification data (authors’ name and journal of publication), search period, number of databases searched, population or settings considered, main results and outcomes observed, and number of participants. From Web of Science (Clarivate Analytics, Philadelphia, PA, USA), we extracted journal rank (quartile) and Journal Impact Factor (JIF).

We categorized the following as primary outcomes: all-cause mortality, need for and length of mechanical ventilation, length of hospitalization (in days), admission to intensive care unit (yes/no), and length of stay in the intensive care unit.

The following outcomes were categorized as exploratory: diagnostic methods used for detection of the virus, male to female ratio, clinical symptoms, pharmacological and non-pharmacological interventions, laboratory findings (full blood count, liver enzymes, C-reactive protein, d-dimer, albumin, lipid profile, serum electrolytes, blood vitamin levels, glucose levels, and any other important biomarkers), and radiological findings (using radiography, computed tomography, magnetic resonance imaging or ultrasound).

We also collected data on reporting guidelines and requirements for the publication of systematic reviews and meta-analyses from journal websites where included reviews were published.

Quality assessment in individual reviews

Two researchers independently assessed the reviews’ quality using the “A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2)”. We acknowledge that the AMSTAR 2 was created as “a critical appraisal tool for systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both” [ 24 ]. However, since AMSTAR 2 was designed for systematic reviews of intervention trials, and we included additional types of systematic reviews, we adjusted some AMSTAR 2 ratings and reported these in Additional file 2 .

Adherence to each item was rated as follows: yes, partial yes, no, or not applicable (such as when a meta-analysis was not conducted). The overall confidence in the results of the review is rated as “critically low”, “low”, “moderate” or “high”, according to the AMSTAR 2 guidance based on seven critical domains, which are items 2, 4, 7, 9, 11, 13, 15 as defined by AMSTAR 2 authors [ 24 ]. We reported our adherence ratings for transparency of our decision with accompanying explanations, for each item, in each included review.

One of the included systematic reviews was conducted by some members of this author team [ 25 ]. This review was initially assessed independently by two authors who were not co-authors of that review to prevent the risk of bias in assessing this study.

Synthesis of results

For data synthesis, we prepared a table summarizing each systematic review. Graphs illustrating the mortality rate and clinical symptoms were created. We then prepared a narrative summary of the methods, findings, study strengths, and limitations.

For analysis of the prevalence of clinical outcomes, we extracted data on the number of events and the total number of patients to perform proportional meta-analysis using RStudio© software, with the “meta” package (version 4.9–6), using the “metaprop” function for reviews that did not perform a meta-analysis, excluding case studies because of the absence of variance. For reviews that did not perform a meta-analysis, we presented pooled results of proportions with their respective confidence intervals (95%) by the inverse variance method with a random-effects model, using the DerSimonian-Laird estimator for τ 2 . We adjusted data using Freeman-Tukey double arcosen transformation. Confidence intervals were calculated using the Clopper-Pearson method for individual studies. We created forest plots using the RStudio© software, with the “metafor” package (version 2.1–0) and “forest” function.

Managing overlapping systematic reviews

Some of the included systematic reviews that address the same or similar research questions may include the same primary studies in overviews. Including such overlapping reviews may introduce bias when outcome data from the same primary study are included in the analyses of an overview multiple times. Thus, in summaries of evidence, multiple-counting of the same outcome data will give data from some primary studies too much influence [ 14 ]. In this overview, we did not exclude overlapping systematic reviews because, according to Cochrane’s guidance, it may be appropriate to include all relevant reviews’ results if the purpose of the overview is to present and describe the current body of evidence on a topic [ 14 ]. To avoid any bias in summary estimates associated with overlapping reviews, we generated forest plots showing data from individual systematic reviews, but the results were not pooled because some primary studies were included in multiple reviews.

Our search retrieved 1063 publications, of which 175 were duplicates. Most publications were excluded after the title and abstract analysis ( n = 860). Among the 28 studies selected for full-text screening, 10 were excluded for the reasons described in Additional file 3 , and 18 were included in the final analysis (Fig. 1 ) [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. Reference list screening did not retrieve any additional systematic reviews.

figure 1

PRISMA flow diagram

Characteristics of included reviews

Summary features of 18 systematic reviews are presented in Table 1 . They were published in 14 different journals. Only four of these journals had specific requirements for systematic reviews (with or without meta-analysis): European Journal of Internal Medicine, Journal of Clinical Medicine, Ultrasound in Obstetrics and Gynecology, and Clinical Research in Cardiology . Two journals reported that they published only invited reviews ( Journal of Medical Virology and Clinica Chimica Acta ). Three systematic reviews in our study were published as letters; one was labeled as a scoping review and another as a rapid review (Table 2 ).

All reviews were published in English, in first quartile (Q1) journals, with JIF ranging from 1.692 to 6.062. One review was empty, meaning that its search did not identify any relevant studies; i.e., no primary studies were included [ 36 ]. The remaining 17 reviews included 269 unique studies; the majority ( N = 211; 78%) were included in only a single review included in our study (range: 1 to 12). Primary studies included in the reviews were published between December 2019 and March 18, 2020, and comprised case reports, case series, cohorts, and other observational studies. We found only one review that included randomized clinical trials [ 38 ]. In the included reviews, systematic literature searches were performed from 2019 (entire year) up to March 9, 2020. Ten systematic reviews included meta-analyses. The list of primary studies found in the included systematic reviews is shown in Additional file 4 , as well as the number of reviews in which each primary study was included.

Population and study designs

Most of the reviews analyzed data from patients with COVID-19 who developed pneumonia, acute respiratory distress syndrome (ARDS), or any other correlated complication. One review aimed to evaluate the effectiveness of using surgical masks on preventing transmission of the virus [ 36 ], one review was focused on pediatric patients [ 34 ], and one review investigated COVID-19 in pregnant women [ 37 ]. Most reviews assessed clinical symptoms, laboratory findings, or radiological results.

Systematic review findings

The summary of findings from individual reviews is shown in Table 2 . Overall, all-cause mortality ranged from 0.3 to 13.9% (Fig. 2 ).

figure 2

A meta-analysis of the prevalence of mortality

Clinical symptoms

Seven reviews described the main clinical manifestations of COVID-19 [ 26 , 28 , 29 , 34 , 35 , 39 , 41 ]. Three of them provided only a narrative discussion of symptoms [ 26 , 34 , 35 ]. In the reviews that performed a statistical analysis of the incidence of different clinical symptoms, symptoms in patients with COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%), gastrointestinal disorders, such as diarrhea, nausea or vomiting (5.0–9.0%), and others (including, in one study only: dizziness 12.1%) (Figs. 3 , 4 , 5 , 6 , 7 , 8 and 9 ). Three reviews assessed cough with and without sputum together; only one review assessed sputum production itself (28.5%).

figure 3

A meta-analysis of the prevalence of fever

figure 4

A meta-analysis of the prevalence of cough

figure 5

A meta-analysis of the prevalence of dyspnea

figure 6

A meta-analysis of the prevalence of fatigue or myalgia

figure 7

A meta-analysis of the prevalence of headache

figure 8

A meta-analysis of the prevalence of gastrointestinal disorders

figure 9

A meta-analysis of the prevalence of sore throat

Diagnostic aspects

Three reviews described methodologies, protocols, and tools used for establishing the diagnosis of COVID-19 [ 26 , 34 , 38 ]. The use of respiratory swabs (nasal or pharyngeal) or blood specimens to assess the presence of SARS-CoV-2 nucleic acid using RT-PCR assays was the most commonly used diagnostic method mentioned in the included studies. These diagnostic tests have been widely used, but their precise sensitivity and specificity remain unknown. One review included a Chinese study with clinical diagnosis with no confirmation of SARS-CoV-2 infection (patients were diagnosed with COVID-19 if they presented with at least two symptoms suggestive of COVID-19, together with laboratory and chest radiography abnormalities) [ 34 ].

Therapeutic possibilities

Pharmacological and non-pharmacological interventions (supportive therapies) used in treating patients with COVID-19 were reported in five reviews [ 25 , 27 , 34 , 35 , 38 ]. Antivirals used empirically for COVID-19 treatment were reported in seven reviews [ 25 , 27 , 34 , 35 , 37 , 38 , 41 ]; most commonly used were protease inhibitors (lopinavir, ritonavir, darunavir), nucleoside reverse transcriptase inhibitor (tenofovir), nucleotide analogs (remdesivir, galidesivir, ganciclovir), and neuraminidase inhibitors (oseltamivir). Umifenovir, a membrane fusion inhibitor, was investigated in two studies [ 25 , 35 ]. Possible supportive interventions analyzed were different types of oxygen supplementation and breathing support (invasive or non-invasive ventilation) [ 25 ]. The use of antibiotics, both empirically and to treat secondary pneumonia, was reported in six studies [ 25 , 26 , 27 , 34 , 35 , 38 ]. One review specifically assessed evidence on the efficacy and safety of the anti-malaria drug chloroquine [ 27 ]. It identified 23 ongoing trials investigating the potential of chloroquine as a therapeutic option for COVID-19, but no verifiable clinical outcomes data. The use of mesenchymal stem cells, antifungals, and glucocorticoids were described in four reviews [ 25 , 34 , 35 , 38 ].

Laboratory and radiological findings

Of the 18 reviews included in this overview, eight analyzed laboratory parameters in patients with COVID-19 [ 25 , 29 , 30 , 32 , 33 , 34 , 35 , 39 ]; elevated C-reactive protein levels, associated with lymphocytopenia, elevated lactate dehydrogenase, as well as slightly elevated aspartate and alanine aminotransferase (AST, ALT) were commonly described in those eight reviews. Lippi et al. assessed cardiac troponin I (cTnI) [ 25 ], procalcitonin [ 32 ], and platelet count [ 33 ] in COVID-19 patients. Elevated levels of procalcitonin [ 32 ] and cTnI [ 30 ] were more likely to be associated with a severe disease course (requiring intensive care unit admission and intubation). Furthermore, thrombocytopenia was frequently observed in patients with complicated COVID-19 infections [ 33 ].

Chest imaging (chest radiography and/or computed tomography) features were assessed in six reviews, all of which described a frequent pattern of local or bilateral multilobar ground-glass opacity [ 25 , 34 , 35 , 39 , 40 , 41 ]. Those six reviews showed that septal thickening, bronchiectasis, pleural and cardiac effusions, halo signs, and pneumothorax were observed in patients suffering from COVID-19.

Quality of evidence in individual systematic reviews

Table 3 shows the detailed results of the quality assessment of 18 systematic reviews, including the assessment of individual items and summary assessment. A detailed explanation for each decision in each review is available in Additional file 5 .

Using AMSTAR 2 criteria, confidence in the results of all 18 reviews was rated as “critically low” (Table 3 ). Common methodological drawbacks were: omission of prospective protocol submission or publication; use of inappropriate search strategy: lack of independent and dual literature screening and data-extraction (or methodology unclear); absence of an explanation for heterogeneity among the studies included; lack of reasons for study exclusion (or rationale unclear).

Risk of bias assessment, based on a reported methodological tool, and quality of evidence appraisal, in line with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method, were reported only in one review [ 25 ]. Five reviews presented a table summarizing bias, using various risk of bias tools [ 25 , 29 , 39 , 40 , 41 ]. One review analyzed “study quality” [ 37 ]. One review mentioned the risk of bias assessment in the methodology but did not provide any related analysis [ 28 ].

This overview of systematic reviews analyzed the first 18 systematic reviews published after the onset of the COVID-19 pandemic, up to March 24, 2020, with primary studies involving more than 60,000 patients. Using AMSTAR-2, we judged that our confidence in all those reviews was “critically low”. Ten reviews included meta-analyses. The reviews presented data on clinical manifestations, laboratory and radiological findings, and interventions. We found no systematic reviews on the utility of diagnostic tests.

Symptoms were reported in seven reviews; most of the patients had a fever, cough, dyspnea, myalgia or muscle fatigue, and gastrointestinal disorders such as diarrhea, nausea, or vomiting. Olfactory dysfunction (anosmia or dysosmia) has been described in patients infected with COVID-19 [ 43 ]; however, this was not reported in any of the reviews included in this overview. During the SARS outbreak in 2002, there were reports of impairment of the sense of smell associated with the disease [ 44 , 45 ].

The reported mortality rates ranged from 0.3 to 14% in the included reviews. Mortality estimates are influenced by the transmissibility rate (basic reproduction number), availability of diagnostic tools, notification policies, asymptomatic presentations of the disease, resources for disease prevention and control, and treatment facilities; variability in the mortality rate fits the pattern of emerging infectious diseases [ 46 ]. Furthermore, the reported cases did not consider asymptomatic cases, mild cases where individuals have not sought medical treatment, and the fact that many countries had limited access to diagnostic tests or have implemented testing policies later than the others. Considering the lack of reviews assessing diagnostic testing (sensitivity, specificity, and predictive values of RT-PCT or immunoglobulin tests), and the preponderance of studies that assessed only symptomatic individuals, considerable imprecision around the calculated mortality rates existed in the early stage of the COVID-19 pandemic.

Few reviews included treatment data. Those reviews described studies considered to be at a very low level of evidence: usually small, retrospective studies with very heterogeneous populations. Seven reviews analyzed laboratory parameters; those reviews could have been useful for clinicians who attend patients suspected of COVID-19 in emergency services worldwide, such as assessing which patients need to be reassessed more frequently.

All systematic reviews scored poorly on the AMSTAR 2 critical appraisal tool for systematic reviews. Most of the original studies included in the reviews were case series and case reports, impacting the quality of evidence. Such evidence has major implications for clinical practice and the use of these reviews in evidence-based practice and policy. Clinicians, patients, and policymakers can only have the highest confidence in systematic review findings if high-quality systematic review methodologies are employed. The urgent need for information during a pandemic does not justify poor quality reporting.

We acknowledge that there are numerous challenges associated with analyzing COVID-19 data during a pandemic [ 47 ]. High-quality evidence syntheses are needed for decision-making, but each type of evidence syntheses is associated with its inherent challenges.

The creation of classic systematic reviews requires considerable time and effort; with massive research output, they quickly become outdated, and preparing updated versions also requires considerable time. A recent study showed that updates of non-Cochrane systematic reviews are published a median of 5 years after the publication of the previous version [ 48 ].

Authors may register a review and then abandon it [ 49 ], but the existence of a public record that is not updated may lead other authors to believe that the review is still ongoing. A quarter of Cochrane review protocols remains unpublished as completed systematic reviews 8 years after protocol publication [ 50 ].

Rapid reviews can be used to summarize the evidence, but they involve methodological sacrifices and simplifications to produce information promptly, with inconsistent methodological approaches [ 51 ]. However, rapid reviews are justified in times of public health emergencies, and even Cochrane has resorted to publishing rapid reviews in response to the COVID-19 crisis [ 52 ]. Rapid reviews were eligible for inclusion in this overview, but only one of the 18 reviews included in this study was labeled as a rapid review.

Ideally, COVID-19 evidence would be continually summarized in a series of high-quality living systematic reviews, types of evidence synthesis defined as “ a systematic review which is continually updated, incorporating relevant new evidence as it becomes available ” [ 53 ]. However, conducting living systematic reviews requires considerable resources, calling into question the sustainability of such evidence synthesis over long periods [ 54 ].

Research reports about COVID-19 will contribute to research waste if they are poorly designed, poorly reported, or simply not necessary. In principle, systematic reviews should help reduce research waste as they usually provide recommendations for further research that is needed or may advise that sufficient evidence exists on a particular topic [ 55 ]. However, systematic reviews can also contribute to growing research waste when they are not needed, or poorly conducted and reported. Our present study clearly shows that most of the systematic reviews that were published early on in the COVID-19 pandemic could be categorized as research waste, as our confidence in their results is critically low.

Our study has some limitations. One is that for AMSTAR 2 assessment we relied on information available in publications; we did not attempt to contact study authors for clarifications or additional data. In three reviews, the methodological quality appraisal was challenging because they were published as letters, or labeled as rapid communications. As a result, various details about their review process were not included, leading to AMSTAR 2 questions being answered as “not reported”, resulting in low confidence scores. Full manuscripts might have provided additional information that could have led to higher confidence in the results. In other words, low scores could reflect incomplete reporting, not necessarily low-quality review methods. To make their review available more rapidly and more concisely, the authors may have omitted methodological details. A general issue during a crisis is that speed and completeness must be balanced. However, maintaining high standards requires proper resourcing and commitment to ensure that the users of systematic reviews can have high confidence in the results.

Furthermore, we used adjusted AMSTAR 2 scoring, as the tool was designed for critical appraisal of reviews of interventions. Some reviews may have received lower scores than actually warranted in spite of these adjustments.

Another limitation of our study may be the inclusion of multiple overlapping reviews, as some included reviews included the same primary studies. According to the Cochrane Handbook, including overlapping reviews may be appropriate when the review’s aim is “ to present and describe the current body of systematic review evidence on a topic ” [ 12 ], which was our aim. To avoid bias with summarizing evidence from overlapping reviews, we presented the forest plots without summary estimates. The forest plots serve to inform readers about the effect sizes for outcomes that were reported in each review.

Several authors from this study have contributed to one of the reviews identified [ 25 ]. To reduce the risk of any bias, two authors who did not co-author the review in question initially assessed its quality and limitations.

Finally, we note that the systematic reviews included in our overview may have had issues that our analysis did not identify because we did not analyze their primary studies to verify the accuracy of the data and information they presented. We give two examples to substantiate this possibility. Lovato et al. wrote a commentary on the review of Sun et al. [ 41 ], in which they criticized the authors’ conclusion that sore throat is rare in COVID-19 patients [ 56 ]. Lovato et al. highlighted that multiple studies included in Sun et al. did not accurately describe participants’ clinical presentations, warning that only three studies clearly reported data on sore throat [ 56 ].

In another example, Leung [ 57 ] warned about the review of Li, L.Q. et al. [ 29 ]: “ it is possible that this statistic was computed using overlapped samples, therefore some patients were double counted ”. Li et al. responded to Leung that it is uncertain whether the data overlapped, as they used data from published articles and did not have access to the original data; they also reported that they requested original data and that they plan to re-do their analyses once they receive them; they also urged readers to treat the data with caution [ 58 ]. This points to the evolving nature of evidence during a crisis.

Our study’s strength is that this overview adds to the current knowledge by providing a comprehensive summary of all the evidence synthesis about COVID-19 available early after the onset of the pandemic. This overview followed strict methodological criteria, including a comprehensive and sensitive search strategy and a standard tool for methodological appraisal of systematic reviews.

In conclusion, in this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all the reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic could be categorized as research waste. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards to provide patients, clinicians, and decision-makers trustworthy evidence.

Availability of data and materials

All data collected and analyzed within this study are available from the corresponding author on reasonable request.

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Acknowledgments

We thank Catherine Henderson DPhil from Swanscoe Communications for pro bono medical writing and editing support. We acknowledge support from the Covidence Team, specifically Anneliese Arno. We thank the whole International Network of Coronavirus Disease 2019 (InterNetCOVID-19) for their commitment and involvement. Members of the InterNetCOVID-19 are listed in Additional file 6 . We thank Pavel Cerny and Roger Crosthwaite for guiding the team supervisor (IJBN) on human resources management.

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IJBN conceived the research idea and worked as a project coordinator. DPOM, TCVG, HMA, IW, AM, LP, VTC, IZG, TPP, ANA, SF, NLB and MSM were involved in data curation, formal analysis, investigation, methodology, and initial draft writing. All authors revised the manuscript critically for the content. The author(s) read and approved the final manuscript.

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Supplementary Information

Additional file 1: appendix 1..

Search strategies used in the study.

Additional file 2: Appendix 2.

Adjusted scoring of AMSTAR 2 used in this study for systematic reviews of studies that did not analyze interventions.

Additional file 3: Appendix 3.

List of excluded studies, with reasons.

Additional file 4: Appendix 4.

Table of overlapping studies, containing the list of primary studies included, their visual overlap in individual systematic reviews, and the number in how many reviews each primary study was included.

Additional file 5: Appendix 5.

A detailed explanation of AMSTAR scoring for each item in each review.

Additional file 6: Appendix 6.

List of members and affiliates of International Network of Coronavirus Disease 2019 (InterNetCOVID-19).

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Borges do Nascimento, I.J., O’Mathúna, D.P., von Groote, T.C. et al. Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews. BMC Infect Dis 21 , 525 (2021). https://doi.org/10.1186/s12879-021-06214-4

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critique paper about pandemic

EDITORIAL article

Editorial: coronavirus disease (covid-19): the impact and role of mass media during the pandemic.

\nPatrícia Arriaga

  • 1 Department of Social and Organizational Psychology, Iscte-University Institute of Lisbon, CIS-IUL, Lisbon, Portugal
  • 2 Department of Psychology and Social Work, Mid Sweden University, Östersund, Sweden
  • 3 Department of Psychiatry and Psychotherapy, Medical School and University Hospital, Eberhard Karls University of Tübingen, Tübingen, Germany

Editorial on the Research Topic Coronavirus Disease (COVID-19): The Impact and Role of Mass Media During the Pandemic

The outbreak of the coronavirus disease 2019 (COVID-19) has created a global health crisis that had a deep impact on the way we perceive our world and our everyday lives. Not only has the rate of contagion and patterns of transmission threatened our sense of agency, but the safety measures to contain the spread of the virus also required social and physical distancing, preventing us from finding solace in the company of others. Within this context, we launched our Research Topic on March 27th, 2020, and invited researchers to address the Impact and Role of Mass Media During the Pandemic on our lives at individual and social levels.

Despite all the hardships, disruption, and uncertainty brought by the pandemic, we received diverse and insightful manuscript proposals. Frontiers in Psychology published 15 articles, involving 61 authors from 8 countries, which were included in distinct specialized sections, including Health Psychology, Personality and Social Psychology, Emotion Science, and Organizational Psychology. Despite the diversity of this collective endeavor, the contributions fall into four areas of research: (1) the use of media in public health communication; (2) the diffusion of false information; (3) the compliance with the health recommendations; and (4) how media use relates to mental health and well-being.

A first line of research includes contributions examining the use of media in public health communication. Drawing on media messages used in previous health crises, such as Ebola and Zika, Hauer and Sood describe how health organizations use media. They offer a set of recommendations for COVID-19 related media messages, including the importance of message framing, interactive public forums with up-to-date information, and an honest communication about what is known and unknown about the pandemic and the virus. Following a content analysis approach, Parvin et al. studied the representations of COVID-19 in the opinion section of five Asian e-newspapers. The authors identified eight main issues (health and drugs, preparedness and awareness, social welfare and humanity, governance and institutions, the environment and wildlife, politics, innovation and technology, and the economy) and examined how e-newspapers from these countries attributed different weights to these issues and how this relates to the countries' cultural specificity. Raccanello et al. show how the internet can be a platform to disseminate a public campaign devised to inform adults about coping strategies that could help children and teenagers deal with the challenges of the pandemic. The authors examined the dissemination of the program through the analysis of website traffic, showing that in the 40 days following publication, the website reached 6,090 visits.

A second related line of research that drew the concern of researchers was the diffusion of false information about COVID-19 through the media. Lobato et al. examined the role of distinct individual differences (political orientation, social dominance orientation, traditionalism, conspiracy ideation, attitudes about science) on the willingness to share misinformation about COVID-19 over social media. The misinformation topics varied between the severity and spread of COVID-19, treatment and prevention, conspiracy theories, and miscellaneous unverifiable claims. Their results from 296 adult participants (Mage = 36.23; 117 women) suggest two different profiles. One indicating that those reporting more liberal positions and lower social dominance were less willing to share conspiracy misinformation. The other profile indicated that participants scoring high on social dominance and low in traditionalism were more willing to share both conspiracy and other miscellaneous claims, but less willing to share misinformation about the severity and spread of COVID-19. Their findings can have relevant contributions for the identification of specific individual profiles related to the widespread of distinct types of misinformation. Dhanani and Franz examined a sample of 1,141 adults (Mage = 44.66; 46.9% female, 74.7% White ethnic identity) living in the United States in March 2020. The authors examined how media consumption and information source were related to knowledge about COVID-19, the endorsement of misinformation about COVID-19, and prejudice toward Asian Americans. Higher levels of trust in informational sources such as public health organizations (e.g., Center for Disease Control) was associated with greater knowledge, lower endorsement of misinformation, and less prejudice toward Asian Americans. Media source was associated with distinct levels of knowledge, willingness to endorsement misinformation and prejudice toward American Asians, with social media use (e.g., Twitter, Facebook) being related with a lower knowledge about COVID-19, higher endorsement of misinformation, and stronger prejudice toward Asian Americans.

A third line of research addressed the factors that could contribute to compliance with the health recommendations to avoid the spread of the disease. Vai et al. studied early pre-lockdown risk perceptions about COVID-19 and the trust in media sources among 2,223 Italians (Mage = 36.4, 69.2% female). They found that the perceived usefulness of the containment measures (e.g., social distancing) was related to threat perception and efficacy beliefs. Lower threat perception was associated with less perception of utility of the containment measures. Although most participants considered themselves and others capable of taking preventive measures, they saw the measures as generally ineffective. Participants acknowledged using the internet as their main source of information and considered health organizations' websites as the most trustworthy source. Albeit frequently used, social media was in general considered an unreliable source of information. Tomczyk et al. studied knowledge about preventive behaviors, risk perception, stigmatizing attitudes (support for discrimination and blame), and sociodemographic data (e.g., age, gender, country of origin, education level, region, persons per household) as predictors of compliance with the behavioral recommendations among 157 Germans, (age range: 18–77 years, 80% female). Low compliance was associated with male gender, younger age, and lower public stigma. Regarding stigmatizing attitudes, the authors only found a relation between support for discrimination (i.e., support for compulsory measures) and higher intention to comply with recommendations. Mahmood et al. studied the relation between social media use, risk perception, preventive behaviors, and self-efficacy in a sample of 310 Pakistani adults (54.2% female). The authors found social media use to be positively related to self-efficacy and perceived threat, which were both positively related to preventive behaviors (e.g., hand hygiene, social distancing). Information credibility was also related to compliance with health recommendations. Lep et al. examined the relationship between information source perceived credibility and trust, and participants' levels of self-protective behavior among 1,718 Slovenians (age range: 18–81 years, 81.7% female). The authors found that scientists, general practitioners (family doctors), and the National Institute of Public Health were perceived as the more credible source of information, while social media and government officials received the lowest ratings. Perceived information credibility was found to be associated with lower levels of negative emotional responses (e.g., nervousness, helplessness) and a higher level of observance of self-protective measures (e.g., hand washing). Siebenhaar et al. also studied the link between compliance, distress by information, and information avoidance. They examined the online survey responses of 1,059 adults living in Germany (Mage = 39.53, 79.4% female). Their results suggested that distress by information could lead to higher compliance with preventive measures. Distress by information was also associated with higher information avoidance, which in turn is related to less compliance. Gantiva et al. studied the effectiveness of different messages regarding the intentions toward self-care behaviors, perceived efficacy to motivate self-care behaviors in others, perceived risk, and perceived message strength, in a sample of 319 Colombians (age range: 18–60 years, 69.9% female). Their experiment included the manipulation of message framing (gain vs. loss) and message content (economy vs. health). Participants judged gain-frame health related messages to be stronger and more effective in changing self-behavior, whereas loss-framed health messages resulted in increased perceived risk. Rahn et al. offer a comparative view of compliance and risk perception, examining three hazard types: COVID-19 pandemic, violent acts, and severe weather. With a sample of 403 Germans (age range: 18–89 years, 72% female), they studied how age, gender, previous hazard experience and different components of risk appraisal (perceived severity, anticipated negative emotions, anticipatory worry, and risk perception) were related to the intention to comply with behavioral recommendations. They found that higher age predicted compliance with health recommendations to prevent COVID-19, anticipatory worry predicted compliance with warning messages regarding violent acts, and women complied more often with severe weather recommendations than men.

A fourth line of research examined media use, mental health and well-being during the COVID-19 pandemic. Gabbiadini et al. addressed the use of digital technology (e.g., voice/video calls, online games, watching movies in party mode) to stay connected with others during lockdown. Participants, 465 Italians (age range: 18–73 years, 348 female), reported more perceived social support associated with the use of these digital technologies, which in turn was associated with fewer feelings of loneliness, boredom, anger, and higher sense of belongingness. Muñiz-Velázquez et al. compared the media habits of 249 Spanish adults (Mage = 42.06, 53.8% female) before and during confinement. They compared the type of media consumed (e.g., watching TV series, listening to radio, watching news) and found the increased consumption of TV and social networking sites during confinement to be negatively associated with reported level of happiness. People who reported higher levels of well-being also reported watching less TV and less use of social networking sites. Majeed et al. , on the other hand, examined the relation between problematic social media use, fear of COVID-19, depression, and mindfulness. Their study, involving 267 Pakistani adults (90 female), suggested trait mindfulness had a buffer effect, reducing the impact of problematic media use and fear of COVID-19 on depression.

Taken together, these findings highlight how using different frames for mass media gives a more expansive view of its positive and negative roles, but also showcase the major concerns in the context of a pandemic crisis. As limitations we highlight the use of cross-sectional designs in most studies, not allowing to establish true inferences of causal relationships. The outcome of some studies may also be limited by the unbalanced number of female and male participants, by the non-probability sampling method used, and by the restricted time frame in which the research occurred. Nevertheless, we are confident that all the selected studies in our Research Topic bring important and enduring contributions to the understanding of how media, individual differences, and social factors intertwine to shape our lives, which can also be useful to guide public policies during these challenging times.

Author Contributions

PA: conceptualization, writing the original draft, funding acquisition, writing—review, and editing. FE: conceptualization, writing—review, and editing. MP: writing—review and editing. NP: conceptualization, writing the original draft, writing—review, and editing. All authors approved the submitted version.

PA and NP received partial support to work on this Research Topic through Fundação para a Ciência e Tecnologia (FCT) with reference to the project PTDC/CCI-INF/29234/2017. MP contribution was supported by the German Research Foundation (DFG, PA847/22-1 and PA847/25-1). The authors are independent of the funders.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated 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.

Acknowledgments

We would like to express our gratitude to all the authors who proposed their work, all the researchers who reviewed the submissions to this Research Topic, and to Rob Richards for proofreading the Editorial manuscript.

Keywords: COVID-19, coronavirus disease, mass media, health communication, prevention, intervention, social behavioral changes

Citation: Arriaga P, Esteves F, Pavlova MA and Piçarra N (2021) Editorial: Coronavirus Disease (COVID-19): The Impact and Role of Mass Media During the Pandemic. Front. Psychol. 12:729238. doi: 10.3389/fpsyg.2021.729238

Received: 22 June 2021; Accepted: 30 July 2021; Published: 23 August 2021.

Edited and reviewed by: Eduard Brandstätter , Johannes Kepler University of Linz, Austria

Copyright © 2021 Arriaga, Esteves, Pavlova and Piçarra. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Patrícia Arriaga, patricia.arriaga@iscte-iul.pt

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated 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.

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The Rules of Contagion: Why Things Spread — and Why They Stop Adam Kucharski Wellcome Collection (2020)

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doi: https://doi.org/10.1038/d41586-020-03555-z

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Volume 26, Number 7—July 2020

Another Dimension

A critique of coronavirus.

Cite This Article

Why did the quiet descend?

Does this plague not know

that apocalypses come with fanfare,

wails of lamentation,

howls of wayward dogs,

explosive blasts?

Or, maybe, silence.

Just shop-window glass crunching underfoot

puncturing the eerie nothing.

Never quiet.

Why does the sun still shine?

Can it not see what transpires

from its lofty throne

above the Earth?

Read the room, sun.

Now’s the time for greyscale filter.

Or, maybe, an eclipse.

One last blinding ray of blazing flare

to scorch the land,

to boil the sea,

to serve up des hommes brûlés

to whichever vengeful deity

dines with us tonight .

Not sunshine.

Never sunshine.

Why can I smell the tulips?

I thought the virus

wiped olfaction from our

paltry list of powers?

Or, maybe, smoke.

You know, from voracious flames

feasting on our foliage and flesh,

the smog of industry,

of mushroom clouds.

Why does that not sting my nostrils?

Not flowers.

Never flowers.

Why does life go on inexorably?

Is Ragnarök not supposed to happen

around now?

Where are the horsemen?

Where are the double gates of Paradise?

What a lame apocalypse:

we’ve been sold a lemon.

Or, maybe, pop culture eschatology

isn’t all it is cracked up to be.

I thought the zombies would be roaming

all my haunts

Never life.

Miss Osen is a Specialty Registrar in the ENT Department at St George’s University Hospitals NHS Foundation Trust, London. Her professional interests include ENT and history of medicine; extracurricular interests include composing bleak poetry and flash/sudden fiction.

DOI: 10.3201/eid2607.201426

Original Publication Date: May 26, 2020

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Table of Contents – Volume 26, Number 7—July 2020

Please use the form below to submit correspondence to the authors or contact them at the following address:

Elana R. Osen, ENT Department, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London, SW17 0QT, UK

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Open Access

Peer-reviewed

Research Article

Public opinion concerning governments’ response to the COVID-19 pandemic

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Statistics, Feng Chia University, Taichung, Taiwan

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Roles Methodology, Writing – review & editing

Affiliation Graduate Institute of Statistics, National Central University, Taoyuan, Taiwan

  • Cathy W. S. Chen, 
  • Tsai-Hung Fan

PLOS

  • Published: March 2, 2022
  • https://doi.org/10.1371/journal.pone.0260062
  • Reader Comments

Fig 1

Governments around the world have implemented numerous policies in response to the COVID-19 pandemic. This research examines the political issues resulting in public opinion concerning their responses to the pandemic via an international perspective. The objectives of this study are to: (1) measure the association and determine whether differences in political support can be attributed to the presence of approval ratings during the pandemic, and to (2) identify exceptional cases based on statistical predictions.

We collect information from several open-sourced surveys conducted between June and September 2020 of public sentiment concerning governments’ response toward COVID-19. The 11 countries in our sample account for over 50% of the world’s Gross Domestic Product (GDP). The study includes country-specific random effects to take into account the data’s clustered structure. We consider “political partisanship” and “pre-pandemic approval ratings in 2019” as two potential explanatory variables and employ a mix-effect regression for bounded responses via variable transformation and the wild bootstrap resampling method.

According to the wild bootstrap method, the mixed-effect regression explains 98% of the variation in approval ratings during the pandemic in September 2020. The findings reveal partisan polarization on COVID-19 policies in the U.S., with opposing supporters most likely to express negative sentiments toward the governing party.

Conclusions

The evidence suggests that approval ratings during the pandemic correlate to differences in political support and pre-pandemic approval ratings, as measured by approval ratings from the views between governing coalition supporters and opponents.

Citation: Chen CWS, Fan T-H (2022) Public opinion concerning governments’ response to the COVID-19 pandemic. PLoS ONE 17(3): e0260062. https://doi.org/10.1371/journal.pone.0260062

Editor: George Vousden, Public Library of Science, UNITED KINGDOM

Received: August 12, 2021; Accepted: January 21, 2022; Published: March 2, 2022

Copyright: © 2022 Chen, Fan. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The minimal data set underlying the results described in this paper can be found in Figs 1 and 2 .

Funding: This work was supported by the Taiwan Ministry of Science and Technology ( https://www.most.gov.tw/ ), grants (MOST109-2118-M-035-005-MY3). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The author has declared that no competing interests exist.

1. Introduction

The COVID-19 pandemic has put governments worldwide under extreme pressure to react fast and decisively. Most of them have implemented numerous policies in response to the pandemic, but they vary substantially across countries. While the challenges appear to be similar for many governing parties, the political reactions differ markedly. The impact of the COVID-19 pandemic on human lives and political attitudes is clearly unquestionable.

Several contemporaneous studies target the impact of COVID-19 on political attitudes and behavior, such as [ 1 , 2 ] comparing respondents’ political attitudes in 15 European countries and finding that public support for governing parties increases in response to lockdown policies. [ 3 ] conclude that approval of incumbent politicians falls as COVID-19 cases grow. [ 4 ] investigate the most important predictor variables influencing the satisfaction of citizens on their governments’ responses to the pandemic based on five covariates for analysis: the number of confirmed cases per million population, the number of deaths per million population, governments’ containment and health policies, their stringency policies, and their economic support policies. Their results reveal that people pay stronger attention to the “number” of government battles against COVID-19 rather than what policies a government may initiate.

Partisanship in many countries has an important influence on attitudes about a government’s policies. People who identify with the current ruling party are remarkably more satisfied with government policies than those who either support the opposition or identify with no political party. The papers mentioned above do not consider one crucial factor, political partisanship, when dealing with government approval issues regarding the COVID-19 pandemic. [ 5 – 7 ] pay attention to partisan differences in U.S. respondents’ views over the COVID-19 pandemic, but their results limit individual behavior and beliefs about the pandemic to be partisan.

This present study aims to measure the strength of relationship and association between variables and to determine whether differences in political support correlate to the presence of public opinion concerning governments’ responses amid the COVID-19 pandemic from an international perspective. We analyze a dataset of 11 advanced economies and discover the hidden factors on public opinion relating to governments’ responses to the pandemic. Each datapoint includes a survey result. The objectives of this study are to: (1) measure the association among pre-pandemic approval ratings, political partisanship, and pandemic approval ratings in 2020; to (2) investigate whether differences in political support and pre-pandemic approval ratings are due to the presence of approval ratings during the pandemic; and to (3) identify exceptional cases based on statistical predictions. The datasets come from public open-sourced surveys and are grouped by political partisanship. The study considers “political partisanship” and “pre-pandemic approval ratings in 2019” as two potential explanatory variables and incorporates a country-specific random effect as a mixed-effect regression for bounded responses via a variable transformation. One can avoid the shortcoming of multiple regression in this study by adding a random effect component in regression. Mixed-effects modeling allows us to examine the condition of interest while also taking into account variability within and across items simultaneously.

We adopt bootstrapping (or resampling) methods to overcome problems of unknown sampling distributions. The bootstrap, proposed initially by [ 8 ], approximates the unknown theoretical sampling distribution of the coefficient estimates by an empirical distribution obtained through a resampling process. This computer-based technique is powerful for presenting statistical inferences without requiring strong assumptions on the sample or the population. We employ wild bootstrap resampling methods by [ 9 , 10 ] for making inferences as the sample does not conform to the assumptions of normality and homoskedasticity.

2. Data description

We collect the public open-sourced data concerning the “majorities of governing party supporters who say their country has dealt with the COVID-19 outbreak well” from the Global Attitudes Survey conducted in June through August 2020, which is available from the Pew Research Center [ 11 ]. However, [ 11 ] mainly focus on political division within the U.S. The purpose of this study is different from the literature mentioned above, as we examine the association and the effects of two potential explanatory variables on public opinion concerning governments’ responses amid the COVID-19 pandemic.

Fig 1 illustrates the approval ratings of respondents who “say their country has dealt with the COVID-19 outbreak well”, grouping them by governing party supporters and non-supporters. We observe among all countries surveyed that governing party supporters are more likely to say their government has done a good job than those who do not support the governing coalition.

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https://doi.org/10.1371/journal.pone.0260062.g001

The information of South Korea in Fig 1 is not included in the Pew Research Center data. The approval rating of South Korea is from [ 12 ] via a web survey from September 9–18, 2020, in which 82.81% of the respondents from the Democratic Party, the current party in charge of the country’s government, support the government’s approach to the pandemic, while 45.12% holding a “no party preference” are satisfied with the government’s response to the 2020 COVID-19 outbreak.

In our study there are 6 European countries (Germany, Netherlands, France, UK, Sweden, and Spain), 2 North American countries (the U.S. and Canada), one Oceania country (Australia), and 2 East Asia countries (Japan and South Korea). The pre-pandemic source is from [ 13 ], who present the economic attitudes among governing coalition supporters and opponents in 2019. Aside from the nine advanced economies in [ 13 ], our study further gathers information on Germany and South Korea. Therefore, we have 22 datapoints for 11 countries. The datapoint of Italy is not in this study since there was no information among governing coalition supporters and opponents in 2019. Nevertheless, these 11 countries in our sample account for over 50% of the world’s Gross Domestic Product (GDP) in 2020.

The information of Germany comes from the survey “in favor of Federal Chancellor remaining in office” in March 2019 [ 14 ]. In South Korea, with its presidential system, we follow the Gallup Korea Daily Opinion [ 15 ]. By political party in South Korea, 80% of Democratic Party supporters evaluated the president’s performance positively, while 20% of non-party supporters showed positive support in 2019.

Fig 2 exhibits pre-pandemic approval ratings, while Table 1 shows the summary approval ratings for the 11 countries pre-pandemic and amid the COVID-19 pandemic. The notation {Y ij } stands for an approval rating, like public opinion, concerning how the governing parties had done a good job dealing with the COVID-19 outbreak in September 2020, while {X i 1 j } stands for an approval rating for governing parties in 2019. Each country has two approval ratings based on governing party supporters (1) and non-supporters (0). We denote this variable as “Support.” We notice considerable heterogeneity in approval ratings during the pandemic in September 2020, as well as approval ratings for the pre-pandemic period in 2019.

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https://doi.org/10.1371/journal.pone.0260062.g002

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https://doi.org/10.1371/journal.pone.0260062.t001

3. Methodology

We first measure the association among all variables based on [ 16 ]. When the continuous variables of interest have extreme values, then in this case a more appropriate measure of a linear relationship is the Spearman rank correlation coefficient. Table 2 reports the Pearson correlation coefficient and Spearman rank correlation coefficient for continuous-continuous variables, {Y, X 1 }. All Pearson and Spearman rank correlation coefficients show only a slight difference. We provide a point-biserial correlation coefficient when dealing with continuous-nominal variables; i.e., {Y, support} and {X 1 , support}.

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A Pearson correlation coefficient is for {Y, X 1 } or {Resp, X 1 }, and Spearman rank correlation coefficient is in (). A point-biserial correlation coefficient appears in boldface.

https://doi.org/10.1371/journal.pone.0260062.t002

critique paper about pandemic

There are several popular bootstrap methods for regression, such as empirical bootstrap, residual bootstrap, and wild bootstrap [ 18 ]. The wild bootstrap developed in [ 10 ] helps overcome heteroskedasticity in the error term. We apply the wild bootstrap resampling method to the mixed-effect model in (1). The wild bootstrap calls for bootstrapping residuals from an “external” distribution. The following steps demonstrate how the wild bootstrap works in our analysis.

critique paper about pandemic

  • We generate independent and identically distributed random variables V ij ~ N (0, 1), i = 1,2, j = 1,…, k .

critique paper about pandemic

  • We repeat Steps 2 and 3 B times and obtain B sets of fitted coefficients and R 2 .
  • We analyze the bootstrap distribution to estimate standard errors and confidence intervals for the parameters.

4. Results and discussion

critique paper about pandemic

https://doi.org/10.1371/journal.pone.0260062.g003

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https://doi.org/10.1371/journal.pone.0260062.t003

Table 4 reports predictions for Australia and U.K.; these datapoints are possible “outliers” when we do not take country-level variability into account. However, when we employ the mixed-effect regression, the predicted approval ratings of 92.54% and 97.92% for non-supporters and supporters in Australia are very close to the observed approval ratings of 93% and 98%, respectively. This is similar for the U.K., whose predicted approval ratings of 37.59% and 70.69% are for non-supporters and supporters, while the observations are 37% and 70%, respectively. However, the situation is very different from the U.S.

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https://doi.org/10.1371/journal.pone.0260062.t004

We find that the most significant residuals appear for the responses of the U.S., in which the predicted approval ratings are 35.28% and 71.79% for non-supporters and supporters while the observed approval ratings are 29% and 76%, correspondingly. The observed approval rating for governing party non-supporters of the U.S. is lower than the predicted value. This study reveals partisan polarization in the U.S. on COVID-19 policies, which agrees with [ 5 , 19 ]. [ 7 ] display that affective polarization influences people’s evaluations of the U.S. government’s response to the COVID-19 pandemic. Opposing partisans are most likely to express negative sentiments about the governing party. Non-supporters of incumbents in the U.S. give “strict” ratings to their governing party, but “generous” ratings in favorable terms come from supporters to their fellow partisans.

Studies suggest that the U.S. COVID-19 response at that time was affected by its political leader [ 7 , 20 ]. The COVID-19 pandemic brought severe threats to the U.S. labor market such as an increase in the unemployment rate, circuit breakers halting the U.S. stock market’s fall, and shocks to the economy and public health [ 21 – 23 ]. These events led to a more recent polarization observed in the U.S. The largest partisan gap in the assessments of the pandemic in this study is from the U.S., as the pandemic exacerbated partisan divisions in the country. The two parties disagreed on public health strategies ranging from mask-wearing to contact tracing [ 11 ]. Therefore, we observe a wider gap of approval ratings in the U.S. between Republicans’ and Democrats’ views of incumbent performance.

5. Conclusions

This study investigates the association and relationship of political partisanship and public opinion concerning governments’ responses to the COVID-19 pandemic via an international perspective. The mixed-effect regression allows for the relationship between approval ratings during the pandemic and two explanatory variables to vary across the country.

The approval ratings of citizens regarding their governments’ responses to the pandemic in September 2020 are based on the attitudes of supporting governing parties and the approval ratings toward such parties in 2019, or the pre-pandemic period. The most important factors in public opinions of a government’s performance in dealing with COVID-19 are partisanship and pre-pandemic approval ratings from the views between governing coalition supporters and opponents. This study deals with cross-sectional data, and if we can collect more datapoints in the near future, then we will be able to monitor the dynamics of political support even further.

As a final remark, the COVID-19 vaccination policy and its implementation became a primary task for governments in 2021. Many challenges still lie ahead for them. A government’s COVID-19 vaccination policy, including its vaccine acquisition, distribution plans, and prioritization approaches, can be additional potential public opinion factors regarding satisfaction relating to governments’ response to the COVID-19 pandemic in 2021.

Acknowledgments

The authors thank the Editor, the Academic Editor, and anonymous referees for their valuable time and careful comments, which have improved this paper.

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  • 11. Dimock M, Wike R. America is exceptional in the nature of its political divide, Pew Research Center Report November 13, 2020. https://www.pewresearch.org/fact-tank/2020/11/13/america-is-exceptional-in-the-nature-of-its-political-divide/
  • 14. Ntv.de, Majority rejects Merkel’s premature end, March 11, 2019. Available from: https://www.n-tv.de/politik/Mehrheit-lehnt-vorzeitiges-Merkel-Ende-ab-article20899545.html
  • 15. Gallup Korea Daily Opinion No. 356, May 5, 2019. Available from: http://www.gallup.co.kr/gallupdb/reportContent.asp?seqNo=1017

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Research Roundup: How the Pandemic Changed Management

  • Mark C. Bolino,
  • Jacob M. Whitney,
  • Sarah E. Henry

critique paper about pandemic

Lessons from 69 articles published in top management and applied psychology journals.

Researchers recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic that were published between March 2020 and July 2023 in top journals in management and applied psychology. The review highlights the numerous ways in which employees, teams, leaders, organizations, and societies were impacted and offers lessons for managing through future pandemics or other events of mass disruption.

The recent pandemic disrupted life as we know it, including for employees and organizations around the world. To understand such changes, we recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic. These papers were published between March 2020 and July 2023 in top journals in management and applied psychology.

  • Mark C. Bolino is the David L. Boren Professor and the Michael F. Price Chair in International Business at the University of Oklahoma’s Price College of Business. His research focuses on understanding how an organization can inspire its employees to go the extra mile without compromising their personal well-being.
  • JW Jacob M. Whitney is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at Kennesaw State University. His research interests include leadership, teams, and organizational citizenship behavior.
  • SH Sarah E. Henry is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at the University of South Florida. Her research interests include organizational citizenship behaviors, workplace interpersonal dynamics, and international management.

Partner Center

A surgical mask hangs on a doorknob as a hand holds another mask next to it.

How a Pandemic Malaise Is Shaping American Politics

Four years later, the shadow of the pandemic continues to play a profound role in voters’ pessimism and distrust amid a presidential rematch.

Confidence in the presidency, public schools, the criminal justice system, the news media and Congress has yet to recover from its slump in surveys in the aftermath of the coronavirus pandemic. Credit... Jonah Markowitz for The New York Times

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Lisa Lerer

By Lisa Lerer ,  Jennifer Medina and Reid J. Epstein

  • March 24, 2024

In March 2020, when Joseph R. Biden Jr. and Donald J. Trump competed for the White House for the first time, American life became almost unrecognizable. A deadly virus and a public health lockdown remade daily routines with startling speed, leaving little time for the country to prepare.

Four years later, the coronavirus pandemic has largely receded from public attention and receives little discussion on the campaign trail. And yet, as the same two men run once again, Covid-19 quietly endures as a social and political force. Though diminished, the pandemic has become the background music of the presidential campaign trail, shaping how voters feel about the nation, the government and their politics.

Public confidence in institutions — the presidency, public schools, the criminal justice system, the news media, Congress — slumped in surveys in the aftermath of the pandemic and has yet to recover. The pandemic hardened voter distrust in government, a sentiment Mr. Trump and his allies are using to their advantage. Fears of political violence, even civil war , are at record highs, and rankings of the nation’s happiness at record lows . And views of the nation’s economy and confidence in the future remain bleak, even as the country has defied expectations of a recession.

“The pandemic pulled the rug from people — you were never quite as secure as you were,” Gov. Kathy Hochul of New York, a Democrat, said in an interview. “We’re starting to get our grounding back. But I think it’s just hard for people to feel good again.”

High rates of office vacancies have crippled urban downtowns, adding to the sense that the country has yet to recover fully. Depression and anxiety rates remain stubbornly high, particularly among young adults. Students remain behind in math and reading , part of the continued fallout from school closures. And even positive news has been met with skepticism: F.B.I. data released this month confirmed that crime declined significantly in 2023, though polling conducted at the end of last year has shown that voters believe otherwise.

Elected officials, strategists, historians and sociologists say the lasting effects of the pandemic are visible today in the debates over inflation, education, public health, college debt, crime and trust in American democracy itself. The lingering trauma from that time, they said, is contributing to a sense of national malaise that voters express in polling and focus groups — a kind of pandemic hangover that appears to be hurting Mr. Biden and helping Mr. Trump in their presidential rematch.

Donald Trump stands behind a lectern adorned with the presidential seal. Behind him to his left is a display showing deaths related to the coronavirus pandemic.

Mr. Biden’s administration passed a robust package of legislation and issued executive actions that steered the country out of the crisis, but voters give the president limited credit for his accomplishments and remain pessimistic about the economy and the nation’s direction. Mr. Trump oversaw the most acute phase of the pandemic, but he casts himself as having presided over a more prosperous and secure country, and continues to lead Mr. Biden in polls.

Philip D. Zelikow, the lawyer who served as the executive director of the commission that investigated the Sept. 11 terror attacks, said the Biden administration moved too quickly to put the pandemic behind it.

“Since the Biden administration never conducted an investigation of the crisis,” Mr. Zelikow said, “and also the Biden administration never developed a serious package of reforms to react to the crisis, the administration basically left the impression that it accepted that the government had failed, but just didn’t want to talk about it anymore.”

Mr. Zelikow, who describes himself as a political independent and says he opposes Mr. Trump, led a nonpartisan team of more than 30 experts called the Covid Crisis Group that investigated the pandemic response and published its findings in a book, “Lessons From the Covid War.” He said that the federal government’s failure to explain how the pandemic happened had accelerated distrust in institutions, and that such an erosion would most likely benefit Mr. Trump, who argues — often falsely — that American politics and government are “rigged” systems.

“If someone like Donald Trump is elected this fall,” Mr. Zelikow said, “the government performance in the Covid crisis will be a significant cause.”

Everywhere and nowhere

Many Americans, of all political persuasions, do not want to revisit that difficult and deadly period. Ryan Hagen, who runs an oral history project documenting the pandemic at Columbia University, said it became difficult to get the participants in his study to continue speaking to the researchers as the crisis wound down.

“The pandemic is everywhere in general in this election and nowhere specific, because it sets the conditions under which this campaign is unfolding,” he said. “Even though hardly any of us talk about it, we are all living in its shadows.”

Mr. Biden has defended his role in pulling the country out of a moment of profound calamity, using his State of the Union address to cast the pandemic as “the greatest comeback story never told.”

At a recent Dallas fund-raiser, the president blamed his predecessor for everything people remember with horror about the pandemic.

“Covid had come to America, and Trump was president,” Mr. Biden told donors, adding, “There was a ventilator shortage. Mobile morgues were being set up. Over — over a million people died. Our loved ones were dying all alone, and they couldn’t even say goodbye to them.”

Biden aides said the campaign was aware of declining trust in government and of increasing isolation. Much of their outreach is focused on reaching voters through family, friends or influencers, rather than through the president or traditional political surrogates.

“Our campaign has a major financial advantage,” said Lauren Hitt, a spokeswoman for the Biden campaign, “and that will allow us to spend the next eight months constantly communicating a very simple truth: Joe Biden delivers where Trump failed, from the pandemic to building an economy that works for everyone to protecting our fundamental rights and freedoms.”

The Trump administration took critical steps, like invoking the Defense Production Act, to accelerate the development of the vaccines that allowed American life to begin to reclaim some semblance of normalcy. But Mr. Trump discusses the pandemic only infrequently. When he does, it is often to blame China for causing it, or the virus for ruining what he reminds audiences was a strong economy. Only Robert F. Kennedy Jr., the independent candidate who attracted a following with his outspoken skepticism of vaccines and his promotion of conspiracy theories, continues to raise the virus frequently as a candidate, often to make allegations of government corruption.

“Americans know Biden has been a disaster and they were far better off under President Trump, which is why President Trump continues to crush Biden in the polls,” said Karoline Leavitt, a Trump campaign spokeswoman.

Bipartisan frustrations

Any political discussion of the crisis is complicated by the widely different ways Americans experienced the most globally disruptive event in a generation.

There is no single unifying pandemic narrative. In California, New York and other Democratic-controlled states, schools and businesses maintained restrictions well into 2021. In Florida, Georgia, South Dakota and other Republican-run states, life resumed some semblance of normalcy far more quickly, even as death tolls mounted.

Since then, memories have been colored by partisan politics. One study published in Nature last year found that people’s recollections of the severity of the pandemic were skewed by the views they later held about vaccines.

“It was the first time in my lifetime that it felt like everything was up for grabs,” said Eric Klinenberg, a professor of sociology at New York University and the author of a new book about the pandemic in New York, “2020: One City, Seven People and the Year Everything Changed.” “Where we’re left today is this emotional experience of feeling like something is off in the country. We’re experiencing long Covid as a social disease.”

Frustrations over Mr. Biden’s handling of the pandemic and the post-pandemic recovery run deep among many Republicans, and even some Democrats.

Kristin Urquiza spoke at the Democratic National Convention in 2020 about her experience watching her father die from complications of Covid. She created a political advocacy group, Marked by Covid, and said she supported Mr. Biden in 2020 because she believed he would comfort victims and console families. She feels differently now.

“He broke his promise to care,” Ms. Urquiza said of the president.

Rather than coming out of the pandemic with a renewed sense of hope, the country has become a far less unified place, she said. She has been deeply frustrated that there have been no efforts to create a permanent national memorial for the more than 1.1 million Americans killed by the disease.

“The families I speak to — the ones living with long Covid and those who have lost loved ones — express a profound sense of abandonment,” Ms. Urquiza said.

A loss of trust

For many Republican voters, the pandemic also hardened their belief that government does more harm than good.

Michael Jackson, 47, a waiter in Las Vegas who was out of work for nearly a year, was furious that much of the state did not reopen more quickly. “I think most politicians showed they are completely oblivious to what’s currently happening beyond their office,” Mr. Jackson said.

Dr. Mary Elizabeth Christian, a retired breast-cancer surgeon who lives in Baton Rouge, La., and is part of Ms. Urquiza’s Marked by Covid group, stayed isolated throughout the pandemic and still wears a mask in public. She avoids restaurants and some of her favorite pastimes, like attending gymnastics meets at Louisiana State University, for which she was a longtime season-ticket holder.

Her parents, who were vaccinated, broke their isolation for a dinner to celebrate their 62nd wedding anniversary in July 2021. Within three days, they both tested positive. They died within two days of each other that August.

Dr. Christian said she had lost trust in all levels of a government that she believes failed to protect its most vulnerable citizens.

“I have been a pretty stalwart pro-life Republican, and I can say that I was disappointed by the Republican Party,” said Dr. Christian, who added that she planned to vote for a third-party candidate this November. “I was very disappointed that a party that has a platform to defend life didn’t do what it took to defend the lives of people who were being exposed to Covid .”

Democrats say a continued dissatisfaction with high food prices and other daily concerns is part of the reason Mr. Biden has struggled to get broad recognition for his legislative successes, even as the economy has improved.

“There’s still some instability that is testing the nerves of Americans coming out of the pandemic,” said Gov. Josh Shapiro of Pennsylvania, a Democrat. “I think that’s very natural for folks to feel that way, given the trauma of Covid and the havoc it wreaked on people’s lives.”

Since taking office, Mr. Biden has won lasting legislative milestones, including a $1 trillion infrastructure package, a $1.9 trillion Covid relief package and major investments to combat climate change .

But some of his post-pandemic programs with the biggest influence on people’s daily lives have not endured. Congress failed to renew a child tax credit payment that sent families monthly checks. Tens of millions of dollars in grants to assist child-care facilities expired, forcing the closure of some providers. Millions of borrowers who had their student loans paused during the pandemic now have payments due, after the Supreme Court rejected an administration plan to forgive $430 billion of student debt. The administration is now pursuing a more piecemeal approach to forgiving that debt.

Alida Garcia, a Democratic strategist and mother of twins, said she harbored a “fired-up rage” during the pandemic and felt almost constantly angry “about the lack of support for mothers in particular.”

“Now, I am equally, if not more, exhausted than at that time, and it feels like things are getting harder for women,” she said.

For others, the anger of those pandemic days has metastasized into a deeper lack of faith in politics.

Julie Fry, a public defender in New Jersey, spent months pushing administrators and politicians in her state to reopen shuttered public schools. Three years later, her young daughters are thriving in school.

But she feels angry and resentful — at politicians from both parties — when she recalls those long months of home-schooling and the mental health toll it took on so many children.

“I feel like Trump was a mess and Biden was a coward about doing what was right for kids,” said Ms. Fry, who describes herself as a staunch liberal. “There were no grown-ups willing to speak up for what kids needed.”

Mostly, though, Ms. Fry is trying to move forward.

“I try not to be bitter,” she said. “I just have to live with the fact that this happened and people who I thought were allies and had the same values failed me and my kids.”

Lisa Lerer is a national political reporter for The Times, based in New York. She has covered American politics for nearly two decades. More about Lisa Lerer

Jennifer Medina is a Los Angeles-based political reporter for The Times, focused on political attitudes and demographic change. More about Jennifer Medina

Reid J. Epstein covers campaigns and elections from Washington. Before joining The Times in 2019, he worked at The Wall Street Journal, Politico, Newsday and The Milwaukee Journal Sentinel. More about Reid J. Epstein

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Trump Media, now publicly traded, could present new conflicts of interest  in a second Trump term.

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  • Open access
  • Published: 20 September 2023

Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review

  • Elfriede Derrer-Merk   ORCID: orcid.org/0000-0001-7241-0808 1 ,
  • Maria-Fernanda Reyes-Rodriguez   ORCID: orcid.org/0000-0002-2645-5092 2 ,
  • Laura K. Soulsby   ORCID: orcid.org/0000-0001-9071-8654 1 ,
  • Louise Roper   ORCID: orcid.org/0000-0002-2918-7628 3 &
  • Kate M. Bennett   ORCID: orcid.org/0000-0003-3164-6894 1  

BMC Geriatrics volume  23 , Article number:  580 ( 2023 ) Cite this article

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Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult’s experiences during the pandemic.

Design and methodology

This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory.

Thirty-two studies met the inclusion criteria and only five papers were of low quality. Most, but not all studies, were from the global north. We identified three themes: desired and challenged wellbeing; coping and adaptation; and discrimination and intersectionality.

Overall, the studies’ findings were varied and reflected different times during the pandemic. Studies reported the impact of mass media messaging and its mostly negative impact on older adults. Many studies highlighted the impact of the COVID-19 pandemic on participants' social connectivity and well-being including missing the proximity of loved ones and in consequence experienced an increase in anxiety, feeling of depression, or loneliness. However, many studies reported how participants adapted to the change of lifestyle including new ways of communication, and social distancing. Some studies focused on discrimination and the experiences of sexual and gender minority and ethnic minority participants. Studies found that the pandemic impacted the participants’ well-being including suicidal risk behaviour, friendship loss, and increased mental health issues.

The COVID-19 pandemic disrupted and impacted older adults’ well-being worldwide. Despite the cultural and socio-economic differences many commonalities were found. Studies described the impact of mass media reporting, social connectivity, impact of confinement on well-being, coping, and on discrimination. The authors suggest that these findings need to be acknowledged for future pandemic strategies. Additionally, policy-making processes need to include older adults to address their needs. PROSPERO record [CRD42022331714], (Derrer-Merk et al., Older adults’ lived experiences during the COVID-19 pandemic: a systematic review, 2022).

Peer Review reports

Introduction

In March 2020 the World Health Organisation declared a pandemic caused by the virus SARS-CoV2 (COVID-19) [ 1 ]. At this time 118,000 cases in 114 countries were identified and 4,291 people had already lost their lives [ 2 ]. By July 2022, there were over 5.7 million active cases and over 6.4 million deaths [ 2 ]. Despite the effort to combat and eliminate the virus globally, new variants of the virus are still a concern. At the start of the pandemic, little was known about who would be most at risk, but emerging data suggested that both people with underlying health conditions and older people had a higher risk of becoming seriously ill [ 3 ]. Thus, countries worldwide imposed health and safety measures aimed at reducing viral transmission and protecting people at higher risk of contracting the virus [ 4 ]. These measures included: national lockdowns with different lengths and frequencies; targeted shopping times for older people; hygiene procedures (wearing masks, washing hands regularly, disinfecting hands); restricting or prohibiting social gatherings; working from home, school closure, and home-schooling.

Research suggests that lockdowns and protective measures impacted on people’s lives, and had a particular impact on older people. They were at higher risk from COVID-19, with greater disease severity and higher mortality compared to younger people [ 5 ]. Older adults were identified as at higher risk as they are more likely to have pre-existing conditions including heart disease, diabetes, and severe respiratory conditions [ 5 ]. Additionally, recent research highlights that COVID-19 and its safety measures led to increased mental health problems, including increased feelings of depression, anxiety, social isolation, and loneliness, potentially cognitive decline [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Other studies reported the consequences of only age-based protective health measures including self-isolation for people older people (e.g. feeling old, losing out the time with family) [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].

Over the past decade, the World Health Organisation (WHO) has recognised the importance of risk communication within public health emergency preparedness and response, especially in the context of epidemics and pandemics. Risk communication is defined as “the real-time exchange of information, advice and opinions between experts or officials, and people who face a threat (hazard) to their survival, health or economic or social well-being” ([ 31 ], p5). This includes reporting the risk and health protection measurements through media and governmental bodies. Constructing awareness and building trust in society are essential components of risk communication [ 32 ]. In the context of the pandemic, the WHO noted that individual risk perception helped to prompt problem-solving activities (such as wearing face masks, social distancing, and self-isolation). However, the prolonged perception of pandemic-related uncertainty and risk could also lead to heightened feelings of distress and anxiety [ 31 , 33 ], see also [ 34 , 35 , 36 , 37 ].

This new and unprecedented disease provided the ground for researchers worldwide to investigate the COVID-19 pandemic. To date (August 2022), approximately 8072 studies have been recorded on the U.S. National Library of Medicine ClinicalTrials.gov [ 38 ] and 12002 systematic reviews have been registered at PROSPERO, concerning COVID-19. However, to our knowledge, there is little known about qualitative research as a response to the COVID-19 pandemic and how it impacted older adults’ well-being [ 39 ]. In particular, little is known about how older people experienced the pandemic. Thus, our research question considers: How did older adults experience the COVID-19 pandemic worldwide?

We use a qualitative evidence synthesis (QES) recommended by Cochrane Qualitative and Implementation Methods Group to identify peer-reviewed articles [ 40 ]. This provides an overview of existing research, identifies potential research gaps, and develops new cumulative knowledge concerning the COVID-19 pandemic and older adults’ experiences. QES is a valuable method for its potential to contribute to research and policy [ 41 ]. Flemming and Noyes [ 40 ] argue that the evidence synthesis from qualitative research provides a richer interpretation compared to single primary research. They identified an increasing demand for qualitative evidence synthesis from a wide range of “health and social professionals, policymakers, guideline developers and educationalists” (p.1).

Methodology

A systematic literature review requires a specific approach compared to other reviews. Although there is no consensus on how it is conducted, recent systematic literature reviews have agreed the following reporting criteria are addressed [ 42 , 43 ]: (a) a research question; (b) reporting database, and search strategy; (c) inclusion and exclusion criteria; (d) reporting selection methods; (e) critically appraisal tools; (f) data analysis and synthesis. We applied these criteria in our study and began by registering the research protocol with Prospero [ 44 ].

The study is registered at Prospero [ 44 ]. This systematic literature review incorporates qualitative studies concerning older adults’ experiences during the COVID-19 pandemic.

Search strategy

The primary qualitative articles were identified via a systematic search as per the qualitative-specific SPIDER approach [ 45 ]. The SPIDER tool is designed to structure qualitative research questions, focusing less on interventions and more on study design, and ‘samples’ rather than populations, encompassing:

S-Sample. This includes all articles concerning older adults aged 60 +  [ 1 ].

P-Phenomena of Interest. How did older adults experience the COVID-19 pandemic?

D-Design. We aim to investigate qualitative studies concerning the experiences of older adults during the COVID-19 pandemic.

E-Evaluation. The evaluation of studies will be evaluated with the amended Critical Appraisal Skills Programme CASP [ 46 ].

R-Research type Qualitative

Information source

The following databases were searched: PsychInfo, Medline, CINAHL, Web of Science, Annual Review, Annual Review of Gerontology, and Geriatrics. A hand search was conducted on Google Scholar and additional searches examined the reference lists of the included papers. The keyword search included the following terms: (older adults or elderly) AND (COVID-19 or SARS or pandemic) AND (experiences); (older adults) AND (experience) AND (covid-19) OR (coronavirus); (older adults) AND (experience) AND (covid-19 OR coronavirus) AND (Qualitative). Additional hand search terms included e.g. senior, senior citizen, or old age.

Inclusion and exclusion criteria

Articles were included when they met the following criteria: primary research using qualitative methods related to the lived experience of older adults aged 60 + (i.e. the experiences of individuals during the COVID-19 pandemic); peer-reviewed journal articles published in English; related to the COVID-19 pandemic; empirical research; published from 2020 till August 2022.

Articles were excluded when: papers discussed health professionals’ experiences; diagnostics; medical studies; interventions; day-care; home care; or carers; experiences with dementia; studies including hospitals; quantitative studies; mixed-method studies; single-case studies; people under the age of 60; grey literature; scoping reviews, and systematic reviews. We excluded clinical/care-related studies as we wanted to explore the everyday experiences of people aged 60 + . Mixed-method studies were excluded as we were interested in what was represented in solely qualitative studies. However, we acknowledge, that mixed-method studies are valuable for future systematic reviews.

Meta-ethnography

The qualitative synthesis was undertaken by using meta-ethnography. The authors have chosen meta-ethnography over other methodologies as it is an inductive and interpretive synthesis analysis and is uniquely “suited to developing new conceptual models and theories” ([ 47 ], p 2), see also [ 48 ]. Therefore, it combines well with constructivist grounded theory methodology. Meta-ethnography also examines and identifies areas of disagreements between studies [ 48 ].

This is of particular interest as the lived experiences of older adults during the COVID-19 pandemic were likely to be diverse. The method enables the researcher to synthesise the findings (e.g. themes, concepts) from primary studies, acknowledging primary data (quotes) by “using a unique translation synthesis method to transcend the findings of individual study accounts and create higher order” constructs ([ 47 ], p. 2). The following seven steps were applied:

Getting started (identify area of interest). We were interested in the lived experiences of older adults worldwide.

Deciding what was relevant to the initial interest (defining the focus, locating relevant studies, decision to include studies, quality appraisal). We decided on the inclusion and exclusion criteria and an appropriate quality appraisal.

Reading the studies. We used the screening process described below (title, abstract, full text)

Determining how the studies were related (extracting first-order constructs- participants’ quotes and second-order construct- primary author interpretation, clustering the themes from the studies into new categories (Table 3 ).

Translating the studies into one another (comparing and contrasting the studies, checking commonalities or differences of each article) to organise and develop higher-order constructs by using constant comparison (Table 3 ). Translating is the process of finding commonalities between studies [ 48 ].

Synthesising the translation (reciprocal and refutational synthesis, a lines of argument synthesis (interpretation of the relationship between the themes- leads to key themes and constructs of higher order; creating new meaning, Tables 2 , 3 ),

Expressing the synthesis (writing up the findings) [ 47 , 48 ].

Screening and Study Selection

A 4-stage screening protocol was followed (Fig.  1 Prisma). First, all selected studies were screened for duplicates, which were deleted. Second, all remaining studies were screened for eligibility, and non-relevant studies were excluded at the preliminary stage. These screening steps were as follows: 1. title screening; 2. abstract screening, by the first and senior authors independently; and 3. full-text screening which was undertaken for almost all papers by the first author. However, 2 papers [ 9 , 23 ] were assessed independently by LS, LR, and LMM to avoid a conflict of interest. The other co-authors also screened independently a portion of the papers each, to ensure that each paper had two independent screens to determine inclusion in the review [ 49 ]. This avoided bias and confirmed the eligibility of the included papers (Fig.  1 ). Endnote reference management was used to store the articles and aid the screening process.

figure 1

Prisma flow diagram adapted from Page et al. [ 50 ]. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71 )

Data extraction

After title and abstract screening, 39 papers were selected for reading the full article. 7 papers were excluded after the full-text assessment (1 study was conducted in 2017, but published in 2021; 2 papers were not fully available in English, 2 papers did not address the research question, 1 article was based on a conference abstract only, 1 article had only one participant age 65 +).

The full-text screening included 32 studies. All the included studies, alongside the CASP template, data extraction table, the draft of this article, and translation for synthesising the findings [ 47 , 48 ] were available and accessible on google drive for all co-authors. All authors discussed the findings in regular meetings.

Quality appraisal

A critical appraisal tool assesses a study for its trustworthiness, methodological rigor, and biases and ensures “transparency in the assessment of primary research” ([ 51 ], p. 5); see also [ 48 , 49 , 50 , 51 , 52 , 53 ]. There is currently no gold standard for assessing primary qualitative studies, but different authors agreed that the amended CASPS checklist was appropriate to assess qualitative studies [ 46 , 54 ]. Thus, we use the amended CASP appraisal tool [ 42 ]. The amended CASP appraisal tool aims to improve qualitative evidence synthesis by assessing ontology and epistemology (Table 1 CASP appraisal tool).

A numerical score was assigned to each question to indicate whether the criteria had been met (= 2), partially met (= 1), or not met (= 0) [ 54 ]; see also [ 55 ]. The score 16 – 22 are considered to be moderate and high-quality studies. The studies scored 15 and below were identified as low-quality papers. Although we focus on higher-quality papers, we did not exclude papers to avoid the exclusion of insightful and meaningful data [ 42 , 48 , 52 , 53 , 54 , 55 , 56 , 57 ]. The quality of the paper was considered in developing the evidence synthesis.

We followed the appraisal questions applied for each included study and answered the criteria either ‘Yes’, ‘Cannot tell’, or ‘No’. (Table 1 CASP appraisal criteria). The tenth question asking the value of the article was answered with ‘high’ of importance, ‘middle’, or low of importance. The new eleventh question in the CASP tool concerning ontology and epistemology was answered with yes, no, or partly (Table 1 ).

Data synthesis

The data synthesis followed the seven steps of Meta-Ethnography developed by Noblit & Hare [ 58 ], starting the data synthesis at step 3, described in detail by [ 47 ]. This encompasses: reading the studies; determining how the studies are related; translating the studies into one another; synthesis the translations; and expressing synthesis. This review provides a synthesis of the findings from studies related to the experiences of older adults during the COVID-19 pandemic. The qualitative analyses are based on constructivist grounded theory [ 59 ] to identify the experiences of older adults during the COVID-19 pandemic (non-clinical) populations. The analysis is inductive and iterative, uses constant comparison, and aims to develop a theory. The qualitative synthesis encompasses all text labelled as ‘results’ or ‘findings’ and uses this as raw data. The raw data includes participant’s quotes; thus, the synthesis is grounded in the participant's experience [ 47 , 48 , 60 , 61 ]. The initial coding was undertaken for each eligible article line by line. Please see Table 2 Themes per author and country. Focused coding was applied using constant comparison, which is a widely used approach in grounded theory [ 61 ]. In particular, common and recurring as well as contradicting concepts within the studies were identified, clustered into categories, and overarching higher order constructs were developed [ 47 , 48 , 60 ] (Tables 2 , 3 , 4 ).

We identified twenty-seven out of thirty-two studies as moderate-high quality; they met most of the criteria (scoring 16/22 or above on the CASP; [ 54 ]. Only five papers were identified as low qualitative papers scoring 15 and below [ 71 , 73 , 74 , 86 , 91 ]. Please see the scores provided for each paper in Table 4 . The low-quality papers did not provide sufficient details regarding the researcher’s relationship with the participants, sampling and recruitment, data collection, rigor in the analysis, or epistemological or ontological reasoning. For example, Yildirim [ 91 ] used verbatim notes as data without recording or transcribing them. This article described the analytical process briefly but was missing a discussion of the applied reflexivity of using verbatim notes and its limitations [ 92 ].

This systematic review found that many studies did not mention the relationship between the authors and the participant. The CASP critical appraisal tool asks: Has the relationship between the researcher and participants been adequately considered? (reflecting on own role, potential bias). Many studies reported that the recruitment was drawn from larger studies and that the qualitative study was a sub-study. Others reported that participants contacted the researcher after advertising the study. One study Goins et al., [ 72 ] reported that students recruited family members, but did not discuss how this potential bias impacted the results.

Our review brings new insights into older adults’ experiences during the pandemic worldwide. The studies were conducted on almost all continents. The majority of the articles were written in Europe followed by North America and Canada (4: USA; 3: Canada, UK; 2: Brazil, India, Netherlands, Sweden, Turkey 2; 1: Austria, China, Finland, India/Iran, Mauritius, New Zealand, Serbia, Spain, Switzerland, Uganda, UK/Ireland, UK/Colombia) (see Fig.  2 ). Note, as the review focuses on English language publications, we are unable to comment on qualitative research conducted in other languages see [ 72 ].

figure 2

Numbers of publications by country

The characteristics of the included studies and the presence of analytical themes can be found in Table 4 . We used the following characteristics: Author and year of publication, research aims, the country conducted, Participant’s age, number of participants, analytical methodology, CASP score, and themes.

We identified three themes: desired and challenged wellbeing; coping and adaptation; discrimination and intersectionality. We will discuss the themes in turn.

Desired and challenged wellbeing

Most of the studies reported the impact of the COVID-19 pandemic on the well-being of older adults. Factors which influenced wellbeing included: risk communication and risk perception; social connectivity; confinement (at home); and means of coping and adapting. In this context, well-being refers to the evidence reported about participants' physical and mental health, and social connectivity.

Risk perception and risk communication

Politicians and media transmitted messages about the response to the pandemic to the public worldwide. These included mortality and morbidity reports, and details of health and safety regulations like social distancing, shielding- self-isolation, or wearing masks [ 34 , 35 , 36 , 37 ]. As this risk communication is crucial to combat the spread of the virus, it is also important to understand how people perceived the reporting during the pandemic.

Seven studies reported on how the mass media impacted participants' well-being [ 23 , 67 , 68 , 70 , 72 , 81 , 85 ]. Sangrar et al. [ 68 ] investigated how older adults responded to COVID-19 messaging: “My reaction was to try to make sure that I listen to everything and [I] made sure I was aware of all the suggestions and the precautions that were being expressed by various agencies …”. (p. 4). Other studies reported the negative impact on participants' well-being of constant messaging and as a consequence stopped watching the news to maintain emotional well-being [ 3 , 67 , 68 , 70 , 72 , 81 , 85 ]. Derrer-Merk et al. [ 23 ] reported one participant said that “At first, watching the news every day is depressing and getting more and more depressing by the day, so I’ve had to stop watching it for my own peace of mind” (p. 13). In addition, news reporting impacted participants’ risk perception. For example, “Sometimes we are scared to hear the huge coverage of COVID-19 news, in particular the repeated message ‘older is risky’, although the message is useful.” ([ 81 ], p5).

  • Social connectivity

Social connectivity and support from family and community were found in fourteen of the studies as important themes [ 9 , 62 , 66 , 67 , 68 , 75 , 76 , 77 , 78 , 79 , 80 , 83 , 84 , 90 ].

The impact of COVID-19 on social networks highlighted the diverse experiences of participants. Some participants reported that the size of social contact was reduced: “We have been quite isolated during this corona time” ?([ 80 ], p. 3). Whilst other participants reported that the network was stable except that the method of contact was different: “These friends and relatives, they visited and called as often as before, but of course, we needed to use the telephone when it was not possible to meet” ([ 77 ], p. 5). Many participants in this study did not want to expand their social network see also [ 9 , 77 , 78 , 79 ]. Hafford-Letchfield et al. [ 76 ] reported that established social networks and relationships were beneficial for the participants: “Covid has affected our relationship (with partner), we spend some really positive close time together and support each other a lot” (p. 7).

On the other hand, other studies reported decreases of, and gaps in, social connectedness: “I couldn’t do a lot of things that I’ve been doing for years. That was playing competitive badminton three times a week, I couldn’t do that. I couldn’t get up early and go volunteer in Seattle” [ 9 , 67 , 75 ]. A loss of social connection with children and grandchildren was often mentioned: “We cannot see our grandchildren up close and personal because, well because they [the parents] don’t want us, they don’t want to risk our being with the kids … it’s been an emotional loss exacerbated by the COVID thing” ([ 68 ] p.10); see also [ 9 , 67 , 78 ]. On the contrary, Chemen & Gopalla [ 66 ] note that those older adults who were living with other family members reported that they were more valued: “Last night my daughter-in-law thanked me for helping with my granddaughter” (p.4).

Despite reports of social disconnectedness, some studies highlighted the importance of support from family members and how support changed during the COVID-19 pandemic [ 9 , 62 , 81 , 83 , 90 ]. Yang et al. [ 90 ] argued that social support was essential during the Lockdown in China: “N6 said: ‘I asked my son-in-law to take me to the hospital” (p. 4810). Mahapatra et al. [ 81 ] found, in an Indian study, that the complex interplay of support on different levels (individual, family, and community) helped participants to adapt to the new situation. For example, this participant reported that: “The local police are very helpful. When I rang them for something and asked them to find out about it, they responded immediately” (p. 5).

Impact of confinement on well being

Most articles highlighted the impact of confinement on older adults’ well-being [ 9 , 62 , 63 , 65 , 67 , 69 , 70 , 72 , 75 , 77 , 78 , 79 , 81 , 82 , 83 , 85 , 89 , 90 ].

Some studies found that participants maintained emotional well-being during the pandemic and it did not change their lifestyle [ 79 , 80 , 82 , 83 , 89 , 92 ]: “Actually, I used this crisis period to clean my house. Bookcases are completely cleaned and I discarded old books. Well, we have actually been very busy with those kind of jobs. So, we were not bored at all” ([ 79 ], p. 5). In McKinlay et al. [ 82 ]’s study, nearly half of the participants found that having a sense of purpose helped to maintain their well-being: “You have to have a purpose you see. I think mental resilience is all about having a sense of purpose” (p. 6).

However, at the same time, the majority of the articles (12 out of 18) highlighted the negative impact of confinement and social distancing. Participants talked of increased depressive feelings and anxiety. For example, one of Akkus et al.’s [ 62 ] participants said: “... I am depressed; people died. Terrible disease does not give up, it always kills, I am afraid of it …” (p. 549). Similarly, one of Falvo et al.’s [ 67 ] participants remarked: “I am locked inside my house and I am afraid to go out” (p. 7).

Many of the studies reported the negative impact of loneliness as a result of confinement on participants’ well-being including [ 69 , 70 , 72 , 78 , 79 , 90 , 93 ]. Falvo et al. [ 67 ] reported that many participants experienced loneliness: “What sense does it make when you are not even able to see a family member? I mean, it is the saddest thing not to have the comfort of having your family next to you, to be really alone” (p. 8).

Not all studies found a negative impact on loneliness. For example, a “loner advantage” was found by Xie et al. ([ 82 ], p. 386). In this study participants found benefits in already being alone “It’s just a part of who I am, and I think that helps—if you can be alone, it really is an asset when you have to be alone” ([ 82 ], p. 386).

Bundy et al. [ 80 ] investigated loneliness from already lonely older adults and found that many participants did not attribute the loneliness to the pandemic: “It’s not been a whole lot, because I was already sitting around the house a whole lot anyway ( …). It’s basically the same, pretty well … I’d pretty well be like this anyway with COVID or without COVID” (p. 873) (see also [ 83 ]).

A study from Serbia investigated how the curfew was perceived 15 months afterward. Some participants were calm: “I realized that … well … it was simply necessary. For that reason, we accepted it as a measure that is for the common good” ([ 70 ], p.634). Others were shocked: “Above all, it was a huge surprise and sort of a shock, a complete shock because I have never, ever seen it in my life and I felt horrible, because I thought that something even worse is coming, that I even could not fathom” ([ 70 ], p. 634).

The lockdowns brought not only mental health issues to the fore but impacted the physical health of participants. Some reported they were fearful of the COVID-19 pandemic: “... For a little while I was afraid to leave, to go outside. I didn’t know if you got it from the air” ([ 75 ]. p. 6). Another study reported: “It’s been important for me to walk heartily so that I get a bit sweaty and that I breathe properly so that I fill my lungs—so that I can be prepared—and be as strong as possible, in case I should catch that coronavirus” ([ 77 ], p. 9); see also [ 70 , 78 , 82 , 85 ].

Coping and adaptation

Many studies mentioned older adults’ processes of coping and adaptation during the pandemic [ 63 , 64 , 68 , 69 , 72 , 75 , 79 , 81 , 85 , 87 , 88 , 89 , 90 ].

A variety of coping processes were reported including: acceptance; behavioural adaptation; emotional regulation; creating new routines; or using new technology. Kremers et al. [ 79 ] reported: “We are very realistic about the situation and we all have to go through it. Better days will come” (p. e71). Behavioural adaptation was reported: “Because I’m asthmatic, I was wearing the disposable masks, I really had trouble breathing. But I was determined to find a mask I could wear” ([ 68 ], p. 14). New routines with protective hygiene helped some participants at the beginning of the pandemic to cope with the health threat: “I am washing my hands all the time, my hands are raw from washing them all the time, I don't think I need to wash them as much as I do but I do it just in case, I don’t have anybody coming in, so there is nobody contaminating me, but I keep washing” ([ 69 ], p. 4391); see also [ 72 ]. Verhage et al. [ 87 ] reported strategies of coping including self-enhancing comparisons, distraction, and temporary acceptance: “There are so many people in worse circumstances …” (p. e294). Other studies reported how participants used a new technology: “I have recently learned to use WhatsApp, where I can make video phone calls.” ([ 88 ], p. 163); see also [ 89 ].

Discrimination -intersectionality (age and race/gender identity)

Seven studies reported ageism, racism, and gender discrimination experienced by older adults during the pandemic [ 23 , 63 , 67 , 70 , 76 , 84 , 88 ].

Prigent et al. [ 84 ], conducted in a New Zealand study, found that ageism was reciprocal. Younger people spoke against older adults: “why don’t you do everyone a favour and drop dead you f******g b**** it’s all because of ones like you that people are losing jobs” (p. 11). On the other hand, older adults spoke against the younger generation: “Shame to see the much younger generations often flout the rules and generally risk the gains made by the team. Sheer arrogance on their part and no sanctions applied” (p.11). Although one study reported benevolent ageism [ 23 ] most studies found hostile ageism [ 23 , 63 , 67 , 70 , 76 , 84 ]. One study from Canada exploring 15 older adult’s Chinese immigrants’ experiences reported racism as people around them thought they would bring the virus into the country. The negative impact on existing friendships was told by a Chinese man aged 69 “I can tell some people are blatantly despising us. I can feel it. When I talked with my Caucasian friends verbally, they would indirectly blame us for the problem. Eventually, many of our friendships ended because of this issue” ([ 88 ], p161). In addition, this study reported ageism when participants in nursing homes felt neglected by the Canadian government.

Two papers reported experiences of sexual and gender minorities (SGM) (e.g. transgender, queer, lesbian or gay) and found additional burdens during the pandemic [ 63 , 76 ]. People experienced marginalisation, stereotypes, and discrimination, as well as financial crisis: “I have faced this throughout life. Now people look at me in a way as if I am responsible for the virus.” ([ 63 ], p. 6). The consequence of marginalisation and ignorance of people with different gender identities was also noted by Hafford- Letchfield et al. [ 76 ]: “People have been moved out of their accommodation into hotels with people they don't know …. a gay man committed suicide, community members know of several that have attempted suicide. They are feeling pretty marginalised and vulnerable and you see what people are writing on the chat pages” (p.4). The intersection of ageism, racism, and heterosexism and its negative impact on people’s well-being during the pandemic reflects additional burden and stressors for older adults.

This systematic literature review is important as it provides new insights into the lived experiences of older adults during the COVID-19 pandemic, worldwide. Our study highlights that the COVID-19 pandemic brought an increase in English-written qualitative articles to the fore. We found that 32 articles met the inclusion criteria but 5 were low quality. A lack of transparency reduces the trustworthiness of the study for the reader and the scientific community. This is particularly relevant as qualitative research is often criticised for its bias or lack of rigor [ 94 ]. However, their findings are additional evidence for our study.

Our aim was to explore, in a systematic literature review, the lived experiences of older adults during the COVID-19 pandemic worldwide. The evidence highlights the themes of desired and challenged wellbeing, coping and adaptation, and discrimination and intersectionality, on wellbeing.

Perceived risk communication was experienced by many participants as overwhelming and anxiety-provoking. This finding supports Anwar et al.’s [ 37 ] study from the beginning of the pandemic which found, in addition to circulating information, that mass media influenced the public's behaviour and in consequence the spread of disease. The impact can be positive but has also been revealed to be negative as well. They suggest evaluating the role of the mass media in relation to what and how it has been conveyed and perceived. The disrupted social connectivity found in our review supports earlier studies that reported the negative impact of people’s well-being [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ] at the beginning of the pandemic. This finding is important for future health crisis management, as the protective health measures such as confinement or self-isolation had a negative impact on many of the participants’ emotional wellbeing including increased anxiety, feelings of depression, and loneliness during the lockdowns. As a result of our review, future protective health measures should support people’s desire to maintain proximity with their loved ones and friends. However, we want to stress that our findings are mixed.

The ability of older adults to adapt and cope with the health crisis is important: many of the reported studies noted the diverse strategies used by older people to adapt to new circumstances. These included learning new technologies or changing daily routines. Politicians and the media and politicians should recognise both older adults' risk of disease and its consequences, but also their adaptability in the face of fast-changing health measures. This analysis supports studies conducted over the past decades on lifespan development, which found that people learn and adapt livelong to changing circumstances [ 95 , 96 , 97 ].

We found that discrimination against age, race, and gender identity was reported in some studies, in particular exploring participants’ experiences with immigration backgrounds and sexual and gender minorities. These studies highlighted the intersection of age and gender or race and were additional stressors for older adults and support the findings from Ramirez et al. [ 98 ] This review suggests that more research should be conducted to investigate the experiences of minority groups to develop relevant policies for future health crises.

Our review was undertaken two years after the pandemic started. At the cut-off point of our search strategy, no longitudinal studies had been found. However, in December 2022 a longitudinal study conducted in the USA explored older adult’s advice given to others [ 99 ]. They found that fostering and maintaining well-being, having a positive life perspective, and being connected to others were coping strategies during the pandemic [ 100 ]. This study supports the results of the higher order constructs of coping and adaptation in this study. Thus, more longitudinal studies are needed to enhance our understanding of the long-term consequences of the COVID-19 pandemic. The impact of the COVID-19 restrictions on older adults’ lives is evident. We suggest that future strategies and policies, which aim to protect older adults, should not only focus on the physical health threat but also acknowledge older adults' needs including psychological support, social connectedness, and instrumental support. The policies regarding older adult’s protections changed quickly but little is known about older adults’ involvement in decision making [ 100 ]. We suggest including older adults as consultants in policymaking decisions to ensure that their own self-determinism and independence are taken into consideration.

There are some limitations to this study. It did not include the lived experiences of older adults in care facilities or hospitals. The studies were undertaken during the COVID-19 pandemic and therefore data collection was not generally undertaken face-to-face. Thus, many studies included participants who had access to a phone, internet, or email, others could not be contacted. Additionally, we did not include published papers after August 2022. Even after capturing the most commonly used terms and performing additional hand searches, the search terms used might not be comprehensive. The authors found the quality of the papers to be variable, and their credibility was in question. We acknowledge that more qualitative studies might have been published in other languages than English and were not considered in this analysis.

To conclude, this systematic literature review found many similarities in the experiences of older adults during the Covid-19 pandemic despite cultural and socio-economic differences. However, we stress to acknowledge the heterogeneity of the experiences. This study highlights that the interplay of mass media reports of the COVID-19 pandemic and the policies to protect older adults had a direct impact on older adults’ well-being. The intersection of ‘isms’ (ageism, racism, and heterosexism) brought an additional burden for some older adults [ 98 ]. These results and knowledge about the drawbacks of health-protecting measures need to be included in future policies to maintain older adults’ well-being during a health crisis.

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The systematic literature review is based on already published articles. And all data analysed during this study are included in this manuscript. No additional data was used.

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Elfriede Derrer-Merk contributed to the design, analysis, and writing the draft. Maria-Fernanda Rodriguez-Reyes contributed to the analysis, revised the draft, and approved the submission. Laura K. Soulsby contributed to the analysis, revised the draft, and approved the submission. Louise Roper contributed to the analysis, revised the draft, and approved the submission. Kate M. Bennett contributed to the design, analysis, writing the draft, and approved the submission.

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Derrer-Merk, E., Reyes-Rodriguez, MF., Soulsby, L.K. et al. Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review. BMC Geriatr 23 , 580 (2023). https://doi.org/10.1186/s12877-023-04282-6

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Impact of COVID-19 outbreak on the mental health in sports: a review

  • Published: 20 April 2023
  • Volume 19 , pages 1043–1057, ( 2023 )

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  • Akash Shukla 1 ,
  • Deepak Kumar Dogra 1 ,
  • Debraj Bhattacharya 1 ,
  • Satish Gulia 2 &
  • Rekha Sharma 3  

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Global pandemic, lockdown restrictions, and COVID-19 compulsory social isolation guidelines have raised unprecedented mental health in the sports community. The COVID-19 pandemic is found to affect the mental health of the population. In critical situations, health authorities and sports communities must identify their priorities and make plans to maintain athletes’ health and athletic activities. Several aspects play an important role in prioritization and strategic planning, e.g., physical and mental health, distribution of resources, and short to long-term environmental considerations. To identify the psychological health of sportspeople and athletes due to the outbreak of COVID-19 has been reviewed in this research. This review article also analyzes the impact of COVID-19 on health mental in databases. The COVID-19 outbreak and quarantine would have a serious negative impact on the mental health of athletes. From the accessible sources, 80 research articles were selected and examined for this purpose such as Research Gate, PubMed, Google Scholar, Springer, Scopus, and Web of Science and based on the involvement for this study 14 research articles were accessed. This research has an intention on mental health issues in athletes due to the Pandemic. This report outlines the mental, emotional and behavioural consequences of COVID-19 home confinement. Further, research literature reported that due to the lack of required training, physical activity, practice sessions, and collaboration with teammates and coaching staff are the prime causes of mental health issues in athletes. The discussions also reviewed several pieces of literature which examined the impacts on sports and athletes, impacts on various countries, fundamental issues of mental health and the diagnosis for the sports person and athletes, and the afterlife of the COVID-19 pandemic for them. Because of the compulsory restrictions and guidelines of this COVID-19 eruption, the athletes of different sports and geographical regions are suffering from fewer psychological issues which were identified in this paper. Accordingly, the COVID-19 pandemic appears to negatively affect the mental health of the athletes with the prevalence and levels of anxiety and stress increasing, and depression symptoms remaining unaltered. Addressing and mitigating the negative effect of COVID-19 on the mental health of this population identified from this review.

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Introduction

COVID-19 is an arising irresistible illness brought about by the newfound Extreme Intense Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The first patient with COVID-19 was identified in Wuhan, Hubei territory as per the research of WHO [World Health Organization] in 2020. In addition, contamination has spread quickly all over the world which resulted in numerous extreme and lethal clinical cases [ 1 ]. It is identified as a highly transmitted disease which can transmit from one person to another person through the droplets of respiration, hands, nose, mouth etc. and also a high infectiousness disease [ 2 ]. The number of mortalities and grimness around the world due to COVID-19 have raised critical general health and well-being concerns. Additionally, identifying, diagnosing, and treating those who were infected, as well as developing medicines, antibodies, and treatments was focused on by all countries and the World Health Organization to decrease the effect of this pandemic [ 3 ]. Finally, governments were constraining nearly a worldwide quarantine [ 4 ]. As a result, all the people maintained social distancing to overcome this issue. Other countries announced several conditions like no contact between people and also lockdown had been declared [ 5 ]. The refugee crisis has also affected the world of sports affairs.

Due to this pandemic, several individuals get affected which leads to disruption, anxiety, stress, stigma, and xenophobia. In a society or community, the act of an individual affects the agitation of the pandemic which contains the level of severity, degree of flow, and aftereffects [ 6 ]. The complete information about the virus and its effects must be known prevent it. To control the spreading of the virus, regional lockdowns were implemented due to the people-to-people transmission of the SARS-CoV-2. The transmission chain has been broken by employing isolation, social distancing, and closing of educational institutes, workplaces, and entertainment venues by which people stay in their homes [ 7 ]. The social and mental health of people gets greatly affected because of these strict actions throughout the board [ 8 ]. The WHO recommends people stay active and available at home to reduce social relationships during the initial wave of COVID-19 and to prevent the spread of the virus. Throughout the world, after the decrease in the count of COVID-19 cases [ 9 , 10 ], and due to the limit of outbreaks in the initial stage, a survey shows that there is a rise in the COVID-19 cases in the second wave in many regions of the world [ 11 ]. Zhao et al . [ 12 ] say that the second wave of infections will be indicated by the control measures and social distance carried out during the first wave of COVID-19 transmission. Due to this, the athletes faced challenges in doing their regular activities with the supervision of their coach and scientific experts, during the placement period.

Several efforts were carried out to prevent the pandemic situation, but there is no clear information about what will be the next steps followed in the upcoming days. The long-lasting effects of Coronavirus have given great worry to the global environment such as declined economy, venture surety, worldwide market stocks, human well-being, daily groceries supply and medical emergency services. To control the spread of the COVID-19 pandemic, strict actions were followed by the governments like severe lockdowns, restriction of social groups, and organisations like sports events and also unnecessary travel has also been prohibited which greatly affects the sports industry and athletes [ 13 ]. For this reason, the athletes were incapable to regulate their regular training sessions as well not participate in any sports events due to suspensions. Further, Turgut et al. [ 14 ] reported the cancellations and postponements of various global sporting events to follow the global health recommendations and to restrict the spread of the infection.

By considering the risk of transmission and the health problems for both the spectators and the field players, several nations have postponed the local professional football leagues [ 15 ]. Severe economic issues and lack of income were the results of COVID-19 and the elite football clubs also face several problems due to this pandemic [ 16 ]. The final match of the UEFA Champions League and other fewer games were postponed by the Union of European Football Associations (UEFA) to March 2020, and the International Olympic Committee (IOC) and the government of Japan also postponed the Tokyo Olympics of 2020 to July 2021 in which there is no change in the name as 2020 Tokyo Olympics [ 17 ]. Totally of about 57% of the 11,000 athletes who have registered for the postponed Olympic games have already met the requirements, following the International Olympic Committee (IOC) However, the majority of these athletes are now confined as a result of the COVID-19 restriction, which was extended till 2021. Therefore, because of the pandemic these big decisions of cancellation and delaying the tournaments were taken due to which many athletes confronted tight limitations to proceed with their normal preparations or practices. Health authorities prescribe these constraints to avoid the public gathering during matches and events that might work to a quick spread of Coronavirus, bringing about extra tension in the medical services framework [ 18 , 19 , 20 ].

To evade the COVID-19 infection during the lockdown self-isolation, limitations, social disconnection arrangements and an environment of uncertainty created an adverse effect on the populace's mental health [ 21 ] and already available evidence appears to affirm these forecasts [ 22 ]. During the first month of internment, nearly 15.8% and 21.6% of the total population of Sain faced depression, anxiety, and post-traumatic symptoms as per the report of González-Sanguino et al . [ 23 ]. Further, WHO [ 18 , 19 , 20 ] is also concerned about these mental health and psycho-social issues due to this pandemic.

However, to understand these outcomes, there is a need to study the results of the coronavirus pandemic in the sports setting. In that context, Trabelsi et al. [ 24 ] also reported that few coaches, sports psychologists and even psychiatrists found some mental issues in athletes, that may cause adverse consequences in their life. Furthermore, Reardon et al. [ 25 ] identified in a narrative review that elite athletes were suffering from various psychological issues at rates identical to or surpassing the common population due to COVID-19. Moreover, the field specialists cautiously screened and observed the athletes during the Coronavirus pandemic and expressed those athletes needed a mental advisory for adjustments. Similarly, Turgut stated that the new measures of self-segregation from others and quarantine affects exercise, practice routine as well as lifestyle resulting in prompt physical and mental challenges for athletes due to the COVID-19 pandemic. Before the COVID-19 pandemic, elite athletes encountered a lot of stressors during their career, the COVID-19 restrictions seem to have amplified all the stressors with negative consequences on the mental health of athletes. Unfortunately, the present literature does not seem to clarify the possible causes and effects of COVID-19 restrictions on athletes. Subsequently, the present narrative review aims to describe the COVID-19 pandemic lockdown influenced the mental health of elite athletes. Specifically, the primary objective of this review is to identify the common psychological distress and stress responses in elite athletes during the COVID-19 pandemic. Consequently, this study aims to identify factors, either positive or negative, related to psychological distress in elite athletes during the COVID-19 pandemic from various research articles.

Impact of COVID-19 on mental health

Several reasons were identified for this. The people who combat the public health factors (like vaccination) and how they deal with the risk of infections and following losses which was mainly due to the psychological measures. The treatment of any infectious disease like COVID-19 is one of the main problems. The maladaptive behaviours, emotional distress and defensive responses were the results due to the Psychological effects of the pandemic [ 26 ]. The people who were affected psychologically will be harsher. We need to accept that, there will be a low lifespan for the people who were affected mentally and this results in poor physical health in normal cases rather than in other populations [ 27 ]. People who already have mental health or use drug problems are more likely to contract COVID-19, and they may face difficulties getting tested or treated and suffer unfavourable medical or mental impacts as a result of the pandemic.

Secondly, from this study, it is predicted that an increase in anxiety and depression symptoms, with some individuals, eventually developing post-traumatic stress disorder, among those who do not already have these diseases. From the evidence, a suggestion is made that throughout the current pandemic, this risk was not fully recognized in China [ 28 ].

Third, an assumption is made that, the people who work in public health, primary care, emergency services, emergency departments and intensive or critical care may face several psychological disorders. While this risk to healthcare workers has been formally identified by the World Health Organization, more needs to be done to manage anxiety and stress in this population and, in the long run, to help prevent burnout, depression, and post-traumatic stress disorder [ 29 ]. However, physical exercise training generally has health benefits and assists in the prevention of several chronic diseases. Moreover, physical activity improves mental health by reducing anxiety, depression, and negative mood and improving self-esteem. Therefore, the beneficial effects of adapted physical activity, based on personalized and tailor-made exercise, in preventing, treating, and counteracting the consequences of COVID-19 are analysed [ 30 ].

Consequently, it is important to identify some of the unique challenges this population currently faces, and understand where our student-athletes are mentally and physically. This is to ensure their needs are addressed, and the health and well-being of this population are protected. [ 31 ] assessed the impact of the COVID-19 pandemic on Canadian high-performance secondary school student-athletes. Student-athletes should be provided additional mental health support during this maelstrom of changes. In particular, additional mental health support for student-athletes should be anticipated in this maelstrom of changes; specific in-home virtual training during the COVID-19 outbreak should be further strengthened and improved to protect the mental and physical health of the athletes, especially to reduce the risk of anxiety and depression.

Impact of COVID-19 on sports

Throughout the world, the COVID-19 virus has been spread virtually, and to stop the spread of this disease, companies, schools, and colleges have been locked down, and general social life like sports and physical activities has also been hindered. The challenges faced by the athletic industry have been mentioned in the COVID-19 lockdown policy. As a result of the fast transmission of this coronavirus, millions of people have lost their lives, the largest indoor and outdoor sports events have been affected, and without the view of competitions the national and international level sports have been postponed or cancelled or rescheduled or location changes happened [ 32 ]. Sports events have been greatly affected by the COVID-19 virus and there are rescheduled international events like the Olympics which have been discussed earlier.

In overall history, this is the first time the cancellation of Olympic Games due to a medical issue [ 33 ]. The financial loss is not only faced by the country Japan but also the 11,000 Olympic athletes and 4400 Paralympians who participated in several sports events of the Olympics also faced this problem. The Olympics is one of the rare and great opportunities for athletes to establish their talents through participation in competitions in front of the total world. Every participant had worked hard and undergo much training for this. During March and April 2020, football clubs would not be required to release players for national teams, according to a FIFA announcement made on March 13, 2020. Without any response, the players have the opportunity to decline. As per the suggestion of FIFA, all international matches must take place outside of the slots, however, the final choice is based upon the administrators of the competition member associations for friendly matches [ 34 ]. Other sporting events, including the Wimbledon championship, the basketball and football tournaments, the athletics championship, handball and ice hockey, cricket, rugby, skiing, weightlifting, and wrestling were able to modify their schedules or can cancel their competitions altogether. For the top athletes, their professional career gets affected greatly due to this rescheduling of the Olympics and several National and International sports events. Along with the discussion about the performance of the athletes, the effects of COVID-19 on sports events must also be considered. Based on factors like location, opposition, score, number of recovery days, and tactical system, the performance of athletes relies [ 35 ].

Because of this lockdown during the COVID-19 pandemic, throughout the world, there are millions of jobs at risk. Rather than the sports person, the people who were engaged in retail and other services, sports industries along with the sports events and leagues that contain transportation, infrastructure facility, travel, tourism, catering, and media broadcasting in the field of sports were also get affected [ 36 ]. A lot of pressure arises among the athletes and professional players because of this postponement of the competitions. Initially, there is no support from the sponsors if they decide to make them fit in the home itself.

Several educational institutions along with sports education are also get affected because of the COVID-19 lockdown, and those stakeholders the local and national ministries, public and private educational institutions, sports organizations, NGOs and the business community, teachers, scholars, coaches, athletes, parents and some young people were also involved.

Impact of COVID-19 on physical activity

Due to the cancellation of sports events during the COVID-19 lockdown, all the other outdoor activities were also restricted. Furthermore, gyms, stadiums, pools, dance and fitness studios, physiotherapy clinics, and parks were forced to close. These factors encouraged athletes to alter their fitness routine and train at home, where they are frequently not observed by qualified health workers or trained coaches. Several athletes have their gym at home or other pieces of exercise equipment which they can use to practise regularly during a lockdown. Their current level of physical fitness should be maintained, or at the very least not decreased, during the home activity period [ 37 ]. However, most people are unfortunately unable to be actively involved in their regular outside individual or group sporting or physical activities. A high level of physical fitness is required by elite athletes irrespective of the specific type of sport. Generally speaking, elite athletes avoid long periods of rest during and at the end of the competitive season [ 38 ].

The immune system and the anti-viral defences were greatly affected because of continuous exercise every day [ 39 ]. A low regulate exercise is resulted due to the order of stay-at-home by the government and closures of parks, gyms, stadiums, and fitness centres to stop the spread of SARS-CoV-2. Since regular exercise can boost the immune system of a sportsperson and can able to treat several co-morbidities like obesity, diabetes, hypertension, and severe heart diseases that make athletes more prone to infections like COVID-19 so it is considered an unacceptable instruction [ 40 ].

Since they affect several sports damage processes and have the potential to improve repeat intervention and prevention, psychological elements underlying the various stages of sports injury are becoming more and more essential [ 41 ]. Rather than the new concept in history, the confinement scenario resulting from COVID-19 shares several issues with the various stages of sports injury encountered by athletes. The sports activity can be reduced due to some inference, reduction in autonomy, alterations in the sports environment, as a single or group there is a lot of chances to increase their records in the sports field, prohibition of activities that are not related with it, personal and family life changes like earlier retirement because of the alterations in the schedule of sports events. Now there is the existence of deeper problems like abuse of substances, social distance, depressive or anxiety episodes, suicidal thoughts, self-esteem problems, and poor sleep quality. Because a poor perception of the quality of sleep can harm the health of a sportsperson, along with the life of the sportsperson the latter factor is also included [ 42 ]. Long periods of isolation may lead to personal growth and development of the psychological processes of sports exercise, which is under the discussion with the writers. There are many adjustments made by sportspersons because of the existence of restrictions throughout the world since they lack the equipment or appropriate areas to develop their training routines effectively [ 43 ]. Because of the prohibition or postponement of all the local, national, and worldwide contests, this fact has prompted us to investigate how the athletes face this complex situation and their issues. Consequently, during this complicated scenario, particular emphasis should be dedicated to specific exercise interventions tailored for subjects and athletes recovering from COVID-19 [ 44 ]. Studying the psychological effects both good and bad that this situation may have a great interest in the individuals.

For the athletes, both the physical and mental issues get increased due to this continuous COVID-19 lockdown. There arises an unstable life for sports players due to the prohibition and rescheduling of sports events. Professional players or athletes feel stressed because they are pushed to the situation to handle all the problems behind them. The level of worry, stress and anxiety may get increased due to the unstable future [ 45 ].

However, to the researcher’s awareness, how far the mental health of the athletes and professionals get affected due to this pandemic has been examined through several researches and surveys. During the continuous lockdown of COVID-19, athletes and sportspeople have faced a lot of issues like difficulties in sleep, sadness and depression rather than an increase in their physical activities [ 46 ]. To address these mental issues and information and illuminate the sports fraternity as well as the general society about the mental challenges an athlete is facing during this COVID-19 outbreak, this review article's impact of a COVID-19 outbreak on the mental health in sports was taken. To examine the current status of the professional athletes who went for a break during the pandemic period and to measure their mental health several surveys have been carried out. An investigation was also carried out to identify the physical and mental activity of the athletes while they stay at the home.

Methodology

The scoping review was carried out for the criteria and procedures outlined in the available systematic literature data factors and Meta-Analysis (PRISMA) with the Scoping Reviews extension.

The available literature on aerobic exercise intervention on body composition in obese females was considered for the present study. Figure  1 shows the PRISMA flowchart. From the sources like Research Gate, Pub Med, Google Scholar, Springer, Scopus, and Web of Science, a total of 80 research articles were gathered for the study and among that 14 sample papers were selected by making use of keywords like COVID-19, SARS-CoV-2, and athletes. Initially, the selected papers were examined whether they are related to the effect of the pandemic on the sportsperson and to confirm this, their respective reference papers were also examined for the full-text articles. The reviews of the particular research papers were also considered. Some of the measures developed to confirm the eligibility were (1) Population: sports person, professional athletes, players, (2) Intervention: COVID-19 pandemic, (3) Types of Study: a comparative study, randomly controlled trials, clinical trials, review papers, systemic review, and meta-analysis, and (4) Outcomes: an establishment of good and fine result related to the psychological health. Age, injury form, or research design will not be avoided. Studies which are not in English, not publishing results, and are not relevant to the COVID-19 pandemic were removed.

figure 1

Flow chart of PRISMA

Scope of PRISMA

To provide guidelines for the creation of protocols and for scientific reviews and meta-analyses that evaluate the efficacy of treatments, the PRISMA has been developed. Without the examination of efficacy, the PRISMA undergoes several reviews because of the fewer protocol instructions, writers are recommended to adopt. A protocol has been demonstrated by the research as a document that defines the reasoning, intended purpose, and intended methodology approach of a systematic review before it begins.

The authors who are involved in the development of systematic review procedures for publication, general consumption, or other purposes should PRISMA initially. To identify whether the protocol contains crucial information, it will be useful for the candidates who write review procedures and as a tool for the reviewers. To get a conclusion about a review, the journalists and reviewers make use of PRISMA to identify the correct protocol.

The structure of this document is the same as the previously established journalistic standards, such as the PRISMA Explanation and Elaboration document; it provides thorough justifications and evidence-based justifications for each checklist item. Examples of effective reporting for each checklist item have been discovered which use systematic review and meta-analysis techniques and are provided throughout this document to help the readers to identify in a better way.

During the development of an efficient review protocol, a particular list of items must be taken into account to focus on the PRISMA, and to get a clear view of the planned review process an extra detail will be more helpful in this process. Rather than the customary of the author, there is a need for more words or space in the PRISMA. Transparency and reproducibility will be available by giving more detailed information about that, and hence in the generated systematic report, the details mentioned must be limited by the authors, and if needed the summary of the report will be given and the finished protocol was referred by the readers or PROSPERO record. Following new journal rules aimed at encouraging reproducibility, this review proposes that full explanations of planned scientific details for systematic reviews are acceptable. There are several checklist elements to match how we picture them appearing in a procedure; publishing them in this order may help readers understand what's going on. If the authors feel that changing the order in which the checklist items appear is necessary, they should do so. In their protocol, authors must describe every PRISMA element.

Discussions

These discussions made use of selected articles as described in the above section. After duplicates were removed from the 80 titles and database citations loaded, just 68 remained. After evaluating the titles and abstracts, 54 were found to be appropriate for full-text examination. Of the 54 papers considered eligible, 40 were eliminated because they were unrelated, lacked full texts, or were abstract-only articles. As a result, 14 publications out of 80 were found to meet the meta-analysis’ inclusion criteria.

Original research articles were cross-sectional studies like comparative studies, random controlled trials, clinical trials, review papers, systemic reviews, and meta-analyses. Table 1 represents the effects of the COVID-19 Outbreak on Psychological Health in Sports. The table illustrates the sample of respondents, variables used for the evaluation and outcomes achieved for the respective studies.

The COVID-19 pandemic is a worldwide challenge. Meier et al . [ 61 ] reported administrations of countries and public health organizations take action most effective commendation to restrict contamination is social distancing. Further, various countries opted for mandatory lockdowns and the closing of public areas for maintaining social distancing. A greater level of mental distress was discovered as a result of changing to new protective measures, according to [ 62 ]'s research on the effects of the coronavirus outbreak on public health. Further, due to this outbreak there are severe mental health disorders like increases in fear, anxiety and depression, gambling problems, sleep and eating disorders, psychological rigidity, obsessive–compulsive disorder, family conflicts, fitness concerns, sedentary lifestyle and negative habits, low mood, large intake of alcohol and drugs, self-harm attempts or suicidal behaviour, and rumination [ 13 , 51 , 53 , 54 , 55 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ] respectively.

Due to the new standards of a pandemic, the athletes have gone through huge changes in their style of living and daily activities, communal relationships, financial-related issues, and loss of goals and satisfaction. In line with these challenges, psychological well-being cannot be isolated from both the physical and mental problems manifestations and related fundamental issues in which the outer injury and recovery may take a long time. Peluso et al . [ 71 ] stated that physical activity has valuable impacts on the control and treatment of various diseases and mental illnesses like depression and anxiety. Further, stress and physical activity effectively affect the factors which influence cardiovascular status [ 72 ]. According to De Matos et al . [ 73 ] the normal problems faced by athletes are physical training, heart diseases, and risk factors. Similarly, during the Coronavirus lockdown, athletes trained less frequently and for shorter periods, which can cause higher depression, anxiety, and stress scores. In addition, [ 74 ] reported that excessively low training load may affect psycho-social engagement among athletes by inducing training-induced physiological and physiological adaptation to aversive preparedness.

Further, McGuine et al . [ 52 ] reported less physical activity and lower quality of life due to school closures and sports cancellations during a pandemic in the USA, and for women players and team sports players’ fewer symptoms like anxiety and depression were faced. Similarly, [ 54 ] also stated that a survey before and after one month of school closure due to the pandemic reported less dissolution of their athletic identity and there is more support from the social environment and the communication between the team members is also increased. Moreover, due to the low quality of sleep and long periods of sleep, they were reported in Spanish handball players due to the decreased training intensity and volume during the pandemic period. Additionally, [ 75 ] mentioned that the numerous physical performance tests of soccer players were get affected in Brazil due to 63 days of quarantine which they conduct during their normal off-season. Furthermore, Haan et al . [ 76 ] reported in their study that Sweden athletes (elite football, ice hockey, and handball players) are concerned about their sport and their careers during this COVID crisis, along with the negative psychological impact of the pandemic.

Furthermore, during this pandemic situation, some players feel lonely and their psychological health gets affected [ 77 ]. Additional factors that have contributed to players' mental suffering include their exclusion from the athletic community, decreased training and activity, a lack of formal coaching, and a lack of social support from fans and the media [ 53 ]. Furthermore, depression, anxiety, and higher athletic identity symptoms were reported in individual and team sports athletes of Turkey and Italy during the lockdown period [ 47 , 73 ] and Uroh and Adewunmi . [ 60 ] also found that single players were more distressed rather than team players during the coronavirus pandemic. Similarly, [ 56 ] stated the negative effect of lockdown on the psychological health and life spheres among youth athletes in Spain. Likewise, individual athletes are more prone to psychological distress than team sports athletes [ 46 , 78 , 79 ]. Individual athletes are at a greater risk because in individual sports athletes are the only responsible person for their success or failure, they cannot get any support from anyone during the competition so they need to work accordingly. Thus, the present circumstance makes individual players more prone to psychological distress in compression to team sports athletes [ 80 , 81 , 82 ]. Additionally, a group of elite and semi-elite athletes from 15 different sports namely soccer, hockey, rugby, cricket, athletics, netball, basketball, endurance running, cycling, track and field, swimming, squash, golf, tennis, and karate in South Africa were examined by Pillay et al. in [ 55 ] to determine the psychological effects of the disease outbreak on their physical, nutritional, and mental health.

Although the outcomes in this study are from various sports, and geographical regions but results were reported the same from every region Athletes are suffering from mental health as well as physical challenges due to the compulsory restrictions and guidelines of this COVID-19 pandemic and during the COVID-19 outbreaks the athletes needed psychosocial services.

COVID-19 impacts on sports and athletes

Several influences were faced by the athletes and players who have long been preparing for the 2020 Tokyo Olympic and Paralympic Games. For some people, no chance is given because of immediate retirement and due to the announcement of a postponement. For instance, British rowing squad member and two-time Olympic medalist Tom Ransley announced his retirement. Eddie Dawkins, who won the silver medal in the Olympics in Rio, recently declared his retirement from the game of track cycling. However, this opportunity is used by others to continue their performance or heal from any injuries they may have experienced the temporal shift in time and rapid modification to optimise their peak. As a consequence, enthusiastic and good attitudes were maintained by the sports players [ 83 ].

Due to the loss of daily, weekly, monthly, and yearly routines, the mental and outer health of the players gets affected. Many athletes lost their normal training routines when the terrible disaster struck in 2011, but the damage was still limited. Athletes carried out their training since many areas of Japan were sufficiently separated from the Fukushima prefecture without the unidentifiable effects of nuclear power plant accidents. The outbreak of COVID-19 has prompted players to stay at home in addition to forcing practically the training centre to be closed. In the Tokyo Olympic and Paralympic Games along with other games, the qualified tournaments get cancelled which was impacted by social distancing measures implemented to prevent the spread of COVID-19. To make it more difficult to achieve a specific goal, these changes have enhanced feelings of doubt, perplexity, and frustration. The athletes work out for a long period due to the impact of practice sessions because there is no way to leave the house and engage in deep and systematic training. Due to this, there may increase in injuries, which in turn could make players feel even more doubt and frustration. Athletes may have increased anxiety due to less communication with their teammates, coaches, and other people.

On the other hand, there is information about athletes who push themselves to a limit as it hurts them and they sometimes feel it necessary to stop [ 84 ]. This type of athlete develops an "exercise dependence prevalence," according to Numanović et al.[ 85 ]research.

The individual athletes felt more stress rather than other team athletes due to this compulsive trend, which is defined by extreme exercise [ 86 ]. Athletes in individual sports are rigorous in their training and intensely focused on their competitive outcomes. The interruption of their preparation due to the limitation in training leads to stress. The roles and responsibilities were divided for the team sports. In comparison with the athletes of individual sports, the team sports participants have more confidence and they can tackle and manage stress easily. As per the frequent discussions with their teammates, the effects of the home lockdown and the confusion around them were seen as less threatening. This condition is acknowledged as a protective factor. As stated earlier, the fitness participants displayed perfection and enjoyment and performs a lot of work. By frequent behaviours like avoiding the issue (avoidance), or acting out of anger and fear they were reacted [ 87 ]. However, the team players may face low stress.

Rather than other types of athletes, the fitness performers show higher values throughout all subscale ratings.

Impacts and actions from various countries

The Health Professionals Council of South Africa has loosened its restrictions on the employment of telehealth to make it more accessible according to the review of Pillay et al. [ 55 ]. This is due to the lockdown and the dangers of COVID-19. Because of travel and financial limitations, just one in four people may contact a sports physician. To know more information about COVID-19, the athletes make use of social media and get knowledge about how effective these channels are at getting important public health messages through to a broad audience. As the healthcare professionals failed to reach the athlete community, there is a need for physicians or other evidence-based channels which were misused for this purpose.

The sports were prohibited at all levels due to COVID-19 outbreaks and the associated quarantine. Because of this situation, the Italian sports community has been subjected to unfavourable psychological pressure, which affects over a long time. Additionally, the Italian sports community is in danger for psychological health due to the psychological effects of COVID-19 outcomes, according to [ 88 ], The players from the youth and amateur levels generated a way for Olympians and professionals who were included in this, along with the supporting staffs, coaches, physical trainers, and managers.

According to [ 89 ], the medical guidelines for COVID-19 treatment in Brazil during the national soccer tournament required RT-qPCR testing of players and coaching staff preceding games and indicated that only asymptomatic players who tested negative be allowed to play.

Even though some teams and players may have less opportunity for testing because of financial inequality. Following this, athletes had a 2.5-fold higher probability of acquiring the disease if a teammate had COVID-19 and were double as likely to be tested for the illness themselves. If the test was conducted by the athlete's team, their chances of being tested will be increased (15-fold).

According to Lundquvist et al. [ 90 ], in France, the quarantine prohibits training in their place, and most of the regional, national, and international tournaments have been cancelled or delayed until further notice. Because of this the anxiety of players increased and their enthusiasm is decreased to return to sports competitions. During the lockdown, athletes had varying options for training depending on their accommodation and the amount of interaction they had with their coaches. To keep the players, motivated, the coaches of various teams scheduled daily workouts using digital tools. In other teams, the athlete's and coaches’ interaction was very rare. A few players questioned the connections and trust with their coaches and their feelings also increased. With the infection of COVID-19, some players and coaches struggled with their symptoms and felt uneasy about their isolation during the crisis. During these times, telephone-based psychological help was also provided.

Because of this lockdown, there is an increase in the negative impact on the physical and mental health of people in India since it reduces physical activity in daily life, as indicated by Jadhav et al. [ 91 ] and the continuous development of COVID-19. The ICC Men's T-20 World Cup editions for 2020 and 2021 were both postponed by one year because of the pandemics during July 2020 declaration by the International Cricket Council. The event was postponed to November 2021 and October 2022, respectively. As per the ICC's declaration on August 8th, the right to host the competition was guaranteed for India in the year 2021 and Australia in the year 2020. The 2021 Women's Cricket World Cup and its semi-final event rescheduled by 1 year as a result of the pandemic.

Based upon the estimation, to improve the country's economy, health, and education Australian sport is funded by $83 billion yearly. A priority on life skills training, ideal social climates, and increased positive results spanning social, personal, and physical sectors have all been recognised as youth sports environments' contributions to children's positive youth development on a worldwide scale. Therefore, [ 92 ] examined how COVID-19 was evaluated by various stakeholders in South Australia's youth sports, including athletes (ages 15 to 18), parents, coaches, and sports administrators.

As the English Football Association (FA) has repeatedly postponed elite men's and women's football matches, the pandemic has put new strains on them. A concern about how much it will be passed out on to elite women's clubs, as more people were already economically insecure. The financial effects of postponed games and reduced television income will be significant in men's football. To put a spotlight on the danger and uncertainty the sport was facing, [ 93 ] examined how the pandemic might affect the development of elite women's football.

The cognitive, affective, and behavioural features of athletes are greatly influenced by perfectionism, which is a significant psychological factor. Through the patterns, it is described as having expectations, perceptions, and evaluations of events, such as "setting excessively high standards, followed by overcritical self-assessment." Perfectionism is associated with a focus on higher goals and more effective performance. Because of this, Lancheva et al. 2022 examined the dominating psychic conditions and perfectionism and their connection to the preferred coping mechanisms during the COVID-19 pandemic among sports students who arrived from Bulgaria and Russia and revealed their specialization based on gender, type of sport, level of qualification, and nationality.

Fundamentals of mental health interviewing and diagnosis of athletes

Without a thorough biopsychosocial clinical assessment, it is impossible to design a management strategy for mental health illnesses and symptoms. In this overview, important details on mental health issues and illnesses in sports that are relevant to this pandemic are addressed. Due to this pandemic, worse mental health conditions and symptoms like anxiety, obsessive–compulsive disorder, PTSD, depression and even suicide attempts among the players [ 94 ], who are frequently young and thus developmental less prepared to deal with the uncertainty that the pandemic has wreaked. The athletes were usually physically active, and due to sudden quit from sports and the migration of much academic education online, some athletes have seen a sudden and significant decrease in physical activity [ 95 ]. The rapid changes might affect mental health because exercise is considered to have both anxiolytic and antidepressant properties [ 96 , 97 ]. Social isolation cancelled events and games and the ensuing uncertainty over how to adjust training schedules, loss of income, loss of training facilities and access to trainers, teammates, and coaches, family infection risks, disruption of daily routines and self-care, anxiety about contracting COVID-19 at sporting events or otherwise, and persistent community distress and additional relevant factors in the mental deterioration health symptoms and disorders in athletes. Because of the changes in sports, professional players get affected mentally (such as those who had planned to retire after 2020 or those who were in their final season of collegiate competition), the pandemic-related sport suspension could mean sport retirement, which could be a particularly difficult transition. Without any willingness, ness if a person gets retired, then there is no plan for this retirement, no support from others and there was a higher level of athlete identity, their mental health may suffer [ 98 ]. Numerous of those unfavourable prognostic variables are probably linked to COVID-19-related retirement from sports.

If a person decides to restart the sport, he may face a lot of stress and anxiety. Due to the return of pandemic training levels, there is an increase in the risk of injury and the play procedures for athletes were returned who previously had COVID-19 that contain a cardiovascular assessment, which has been reported to cause anxiety in certain athletes [ 99 ]. Trust and collaboration during sporting events [ 100 ] get affected because of the tactile communication such as giving high fives or pats on the back which has historically been crucial among teammates, but the athletes must need to get back in later days.

Healthcare professionals may identify new mental health conditions among the players at this time because of the contextual stresses [ 101 ], but they should be careful not to assign pathologies to normal and not to combat the stress which results in distress or dysfunction. Virtual appointments may be used for a variety of purposes. The diagnosis of a fresh case of ADHD, however, is more difficult to determine without a physical examination. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) states that certain symptoms for such a diagnosis must have been present before the age of 12 [ 102 ], even though were not aware of the player. Stimulants are not authorized when certain diagnostic requirements are met, according to the NCAA, WADA, and some professional sports leagues. According to the NCAA, the usage of ADHD rating scales is one of the major needs for the use of medications [ 103 ] But according to WADA, "there should ideally be a reference in the diagnostic assessment to use allowed diagnostic instruments." There is a challenging test conducted digitally because it can be time-consuming and complex. The athletes should be informed if any changes are happening in the timescales for the identification of disease, and virtual solutions should be investigated if possible.

In the time of the pandemic, the evaluation for suicidal behaviour is essential, and the linked crisis planning influences the management of a cure for the player, particularly for the degree of care advised. Although definitive data are not yet available, some people worry that the pandemic may raise the probability of suicide [ 104 ]. Social isolation, financial struggles, and difficulties to gain standard mental health care during the pandemic are a few factors which will enhance the risk which must be investigated. Firearms sales were used in large numbers in recent days in several countries and providers who are worried about the safety of players in mental health should investigate access to firearms. Guns are linked to an increased risk of suicide even if they are not bought to kill one [ 105 ]. To control the other suicide methods (e.g., excessive medication, and access to high buildings), a suicide risk analysis should be carried out. There is a large number of suicide attempts during the late spring in the Northern Hemisphere and during the effects of COVID-19, it is relatively high, especially during spring and summer sports.

Psychological aspects of return to sport after COVID-19

During the final events of athletes, individual and team training has been hindered which harms the mental health of players during the quarantine and come to a mindset to play again. Athletes are currently dealing with issues like social isolation, career disruption, and restricted access to training environments and instructors, which can harm their general well-being and result in a terrible performance, according to a Simons et al. editorial [ 106 ]. The debate has emerged about the potential that some athletes may have the benefits of training or disadvantage depending on the region due to variations in the degree of confinement around the world. If the athlete is not aware of when to complete the training and competition then he may face tension, anxiety, and sadness. Several surveys say that popular athletes have overcome depression in the baseline similar to the general population. [ 107 ] found that group training greatly increased pain tolerance and may have boosted the types of activity in comparison with taking training alone. During the period of outbreak, the National Alliance on Mental Illness has generated several recommendations namely [ 108 ] (1) a structured work environment, (2) attire and structured breaks which is a normal routine, (3) continuous physical workout with “mindfulness” along with quiet time and deep breathing, (4) safe of self-talk, conversation with other people, nutrition, creating a daily routine for the normal day, (5) available among the friends, family, and colleagues, (6) making use of video tools to connect manually, (7) referring the National Alliance on Mental Health Illness.

During the period of isolation and less exercise among the team, the ideas and guidelines were used which were provided by National Alliance on Mental Health organization and it was taken as a reference.

Throughout the world, there are more effects raised due to this COVID-19 outbreak in the field of sports as well as it also affects the physical activity of sportspersons and other players. Enormous effects of COVID-19 were realized not only in the world of athletics, but also in society, as a result of which businesses, workplaces, social engagements, universities, and educational institutions had to close down quickly. Globally, few longitudinal studies compared mental health before and during COVID-19 and found an increase in anxiety and depression symptoms. However, the majority of significant outdoor and indoor athletic events at the world, regional, and national levels have been cancelled or postponed as a result of COVID-19. The health of all the people around the world gets affected by COVID-19. The present situation requires raising awareness in public, which can be helpful to deal with this calamity. This perspective article provides a detailed overview of the effects of the COVID‐19 outbreak on the mental health of people. An effective plan to safeguard the mental health of this already vulnerable population of athletes is crucial. As sportspeople and athletes are significantly affected by mental disease, this study focuses on mental health, psychological responses, and suffering among them. This study's review includes a selection of articles based on PRISMA meta-analysis. Out of 80 papers found using Research Gate, PubMed, Google Scholar, Springer, Scopus, and Web of Science, 14 articles relevant to the literature were chosen. Furthermore, these selected papers are used in the discussions.

Several risk factors have been identified such as mental and cardiovascular disease in athletes which results in stresses like isolation, a lack of exercise, a low income, and fear of losing their jobs. The stress leads to COVID-19 exposure. To fight the coronavirus outbreak, organizations for occupational therapy and psychosocial stressors and their health will get affected. Many millions of jobs are at stake worldwide as a result of the COVID-19 lockdown, not just for sports professionals but also for individuals in allied retail and athletic services businesses associated with leagues and tournaments. Essentially, the evidence presented in this study supports the hypothesis that the pandemic affects mental health problems in sportsmen. Athletes' mental health concerns are exacerbated by a lack of training, needed physical activity, practise sessions, and teamwork with teammates and coaching staff. The beneficial effects of physical exercise in improving quality of life and well-being have been extensively documented. An adapted physical activity program may represent an important factor to prevent COVID-19 infection, as well as a useful complementary tool to improve the physical and psychological outcomes of COVID-19-affected patients. A suitable exercise program may strengthen the athletes, providing immune protection in the long term and reducing treatment costs. The influence on sports and athletes, the impact on various nations, basic concerns of mental health and diagnosis for sportspeople and athletes, and the COVID-19 pandemic's afterlife for them were all explored in the review. The findings showed that COVID-19 has an impact on elite athletes’ mental health and was linked with stress, anxiety and psychological distress. The magnitude of the impact was associated with athletes’ mood state profile, personality and resilience capacity. Therefore, strongly believe that the findings from this review would help athletes in addressing and mitigating the rise in mental health disorders, which could prove worse than the current pandemic itself. Based on the findings of this study, it was concluded that the athletes of different sports and geographical regions are suffering from mental health issues due to the compulsory restrictions and guidelines of this COVID-19 outbreak.

Future application

Pandemic isolation has created immense pressure on athletes to regulate their training, execute their specific plans, maintain their social networks, to participate in targeted sports events and tournaments, respectively. Further, a finding of this study will support the professionals to prepare or establish specific psychological programmes to motivate and enables athletes to regulate their normal practices during the COVID-19 outbreak.

Relevance for clinical practice

This study was to review the shreds of evidence for the effect of a COVID-19 outbreak on mental health in sports. The findings of the study concluded that the athletes of different sports and geographical regions are suffering from mental health issues due to the compulsory restrictions and guidelines of this COVID-19 outbreak.

Data availability

Data sharing does not apply to this article as no datasets were generated or analysed during the current study.

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Shukla, A., Dogra, D.K., Bhattacharya, D. et al. Impact of COVID-19 outbreak on the mental health in sports: a review. Sport Sci Health 19 , 1043–1057 (2023). https://doi.org/10.1007/s11332-023-01063-x

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The Impact of COVID-19 Pandemic on Family Well-Being: A Literature Review

Maria gayatri.

1 Directorate for Development of Service Quality of Family Planning, National Population and Family Planning Board (BKKBN), Jakarta, Indonesia

Mardiana Dwi Puspitasari

2 Research Center for Population, National Research and Innovation Agency (BRIN), Jakarta, Indonesia

Background: COVID-19 has changed family life, including employment status, financial security, the mental health of individual family members, children's education, family well-being, and family resilience. The aim of this study is to analyze the previous studies in relation to family well-being during the COVID-19 pandemic. Methods: A literature review was conducted on PubMed, Medline, Web of Science, and Scopus for studies using a cross-sectional or quasi-experimental design published from their inception to October 15, 2020, using the keywords “COVID-19,” “pandemic,” “coronavirus,” “family,” “welfare,” “well-being,” and “resilience.” A manual search on Google Scholar was used to find relevant articles based on the eligibility criteria in this study. The presented conceptual framework is based on the family stress model to link the inherent pandemic hardships and the family well-being. Results: The results show that family income loss/economic difficulties, job loss, worsening mental health, and illness were reported in some families during the COVID-19 pandemic. Family life has been influenced since the early stage of the pandemic by the implementation of physical distancing, quarantine, and staying at home to curb the spread of coronavirus. During the pandemic, it is important to maintain family well-being by staying connected with communication, managing conflict, and making quality time within family. Conclusion: The government should take action to mitigate the social, economic, and health impacts of the pandemic on families, especially those who are vulnerable to losing household income. Promoting family resilience through shared beliefs and close relationships within families is needed during the COVID-19 pandemic.

Introduction

Coronavirus disease 2019 (COVID-19) is a form of pneumonia caused by the severe acute respiratory coronavirus syndrome 2 (SARS-CoV-2) ( Lai et al., 2020 ). The appearance of COVID-19 becomes an outbreak in December 2019 in China. The coronavirus disease can be transmitted through the respiratory tract, digestive system, and also mucosal surface ( Ye et al., 2020 ). Fever, cough, shortness of breath, and diarrhea are the symptoms of COVID-19 infection at the onset. The pandemic of COVID-19 has brought many changes to all the communities, workers, and families to reduce the spread of the coronavirus and limit its impact on health, societal, and economic consequences. This pandemic had a powerful impact on family life. Mental resilience is required for coping strategies during the pandemic ( Barzilay et al., 2020 ).

COVID-19 has changed family life, including employment, financial instability, the mental health of family members, children's education, family well-being, and family resilience. People start to protect themselves from the spread of the coronavirus by physical and social distancing, sheltering-in-place, restricting travel, and implementing health protocols. Some public places are abrupt closures, such as schools, childcare centers, community programs, religious places, and workplaces. This change impacts social life, such as isolation, psychological distress, substantial economic distress, depression, and also domestic violence, including child abuse ( Campbell, 2020 ; Patrick et al., 2020 ). The Internet has become the most important thing to support all activities while staying at home and staying connected with others.

Families are forced to maintain a work–life balance in the same place with all family members during the pandemic ( Fisher et al., 2020 ). Parents are working from home while children are in school. Therefore, parents and children should share the space for their activities at home. On the one hand, parents should focus on their job to maintain their working target in order to avoid losing their job, heighten their financial concerns, sustain their food security, maintain healthy habits, and keep their family members safe from COVID-19. Balancing life during the pandemic is challenging ( Fisher et al., 2020 ). Fathers and mothers should work together not only on the paid job but also on domestic chores, childcare, and teaching their children.

The aim of this literature review is to identify the impact of the COVID-19 pandemic on family well-being based on the previously published articles.

Literature Review

The coronavirus pandemic has become a public health crisis or disaster that has had an impact on family well-being both directly and indirectly. An infectious disease outbreak has spread rapidly, severely disrupted the world, and resulted in morbidity and mortality. This pandemic produced not only a health crisis, but also a social crisis among the population ( Murthy, 2020 ).

The conceptual framework was adapted from McCubbin and Patterson's family stress model. Using McCubbin and Patterson's family stress model, stressful life events (external stressors) had an impact on family life. During the COVID-19 pandemic, there was a profound impact on Indonesian economic growth and labor market, indicating that more people were living in poverty ( Gandasari & Dwidienawati, 2020 ; Olivia et al., 2020 ; Suryahadi et al., 2020 ). Stress-frustration theory indicates that diminished economic resources in the family could add to stress, frustration, and conflict in interpersonal interactions, which might increase the risk of men committing violence against women ( Kaukinen, 2020 ). It means that unemployment and economic instability contributed to the family stress. Furthermore, the underlying pandemic difficulties posed a threat to Indonesian people's mental health ( Abdullah, 2020 ; Megatsari et al., 2020 ). A higher risk of stress could lead to domestic violence. Domestic violence was defined as a coping mechanism for stress induced by social-systemic variables, such as poverty, unemployment, homelessness, loneliness, and ecological characteristics ( Zhang, 2020 ). Individual stress and other factors (such as job loss, lower income, limited resources and support, and hazardous and harmful alcohol use) were associated with domestic violence during the COVID-19 pandemic ( Campbell, 2020 ). Indonesian children were also affected. A recent study found that the financial burden within the family constituted a risk to Indonesian child competency and adjustment ( Riany & Morawska, 2021 ). The well-being of children might be dependent on the well-being of their parents ( Dahl et al., 2014 ). As a result, the inherent pandemic hardships posed a risk to family well-being.

According to the family stress model, the family must engage in an active process to balance external stressors with personal and family resources and a positive outlook on COVID-19 in order to develop and sustain an adaptive coping strategy to face the inherent pandemic hardships and eventually reach a level of family well-being. Mental health and prevention from the risk of mental disorders were required by incorporating individuals, families, communities, and government during and after pandemic events, so that family well-being and resilience could be achieved and improved ( Murthy, 2020 ). Resilience was characterized as a process that encompassed not just successfully adapting and functioning after experiencing adversity or crisis, but also the possibility of personal and relationship transformation and positive growth as a result of adversity ( Walsh, 1996 ). There were three fundamental processes to becoming resilient: shared belief systems, organizational patterns, and communication processes within the family ( Walsh, 1996 ).

A literature review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2009 ). This study was conducted from the beginning of March 2020, when the first positive case occurred in Indonesia, to October 1, 2020.

In order to meet the research objective, the authors carried out the literature review by searching various databases. The present study uses an integrative review to summarize the existing evidence to obtain a comprehensive understanding of the impact of the COVID-19 pandemic on family welfare. PubMed, Medline, Web of Science, and Scopus are selected as the main sources of the article's database. A manual search on Google Scholar is also conducted to find relevant articles based on the study’s eligibility criteria. The following keywords are used to perform the search, such as “COVID-19,” “pandemic,” “coronavirus,” “family,” “welfare,” “resilience,” and “mental health.” A total of 67 articles with the matching keywords were primarily retrieved.

Studies were eligible for inclusion if the studies are cross-sectional, experimental designs, or cohort studies describing the impact of the pandemics on family well-being both physical and mental well-being. Studies had to be published from the inception of the pandemic to October 15, 2020, in a journal with impact factors, English-language studies, and related to the COVID-19 pandemic. However, some articles are excluded because they are duplicate articles or studies in non-English language. We also excluded opinions, letters to the editor, and systematic reviews or meta-analyses. Moreover, unpublished articles and reports are also excluded from this study. Finally, based on the inclusion and exclusion criteria, eight articles met the inclusion criteria, and the data were extracted for the next analysis.

Based on eight articles, the data were extracted to include some important information, such as (1) Country/Region, (2) The purpose of the study, (3) Methods of the study, (4) The respondents (sample size and sample characteristics), (5) the main result of the study. The data extraction is done using a form on Microsoft Excel. All articles in this study were evaluated using narrative synthesis and presented data in the table forms.

A total of eight articles were selected for this study, with various subjects consisting of children, adolescents, adults, and parents. The literature review in this study is based on previous studies in the United States, Canada, Brazil, the United Kingdom, Germany, Ireland, Israel, China, Taiwan, Japan, and Bangladesh. Common impacts are physiological stress, anxiety, depression, income loss, fear, economic hardship, food insecurity, and family violence. Higher resilience is associated with fewer COVID-19-related worries, lower anxiety, and lower depression. Greater parental control is associated with lower stress and a lower risk of child abuse. Positive children were infected by the household contact. The results of the review are shown in Table 1 .

Table 1.

Characteristics of the Studies.

Coronavirus diseases put families in uncertain conditions without clarity on how long the pandemic situation will last. The pandemic has caused many challenges that impact on family unit and the functions of the family unit, including distraction in family relationships ( Luttik et al., 2020 ). These challenges will have an influence on family well-being in many aspects, such as loss of community, loss of income, resources, planned activities, and travel due to quarantine. The concern about nuclear family members increased because they did not want their family to become ill from the coronavirus. It is suggested to not visit the older members or those with serious illnesses who are more vulnerable to the virus.

Family life has been influenced since the early stage of the pandemic by the implementation of physical distancing, quarantine, and staying at home to curb the spread of coronavirus. Physical and social distancing are effective mitigations to reduce the spread of the coronavirus during the outbreak. However, distancing requires adaptation among family members to improve family well-being. Sheltering-in-place makes more frequent interactions among family members because they have limited opportunities to have a leisure time into the outside world. This condition, on the one hand, can create a quality time and intimate interactions among family members, but on the other hand, it may lead to long-standing high conflicts, occasionally domestic violence, and divorce ( Lebow, 2020b ). In this condition, a home can be described as a place of warmth, love, and safety or as a place of intimidation, abuse, and fear ( Hitchings & Maclean, 2020 ). Other studies found a positive outlook on the COVID-19 pandemic regarding the necessity of focusing on and enjoying family relationships, especially taking advantage of the pandemic's gift of extended time together ( Evans et al., 2020 ; Holmberg et al., 2021 ). This optimistic attitude could function as a shared belief system within the family, resulting in family resilience. Working life balance at home during the time of COVID-19 provides a new chance for internal conflicts, disagreements, and arguments in which parents try to play their multi-roles with all family members to mitigate some problems such as unemployment and financial instability ( Lebow, 2020b ). Family income loss/economic difficulties, job loss, experienced hardships during the pandemic, worsening mental and behavioral health, stress, high anxiety, distress about family contracting COVID-19, and illness are reported in some families during the COVID-19 pandemic.

Domestic violence related to mental and physical health may happen during the COVID-19 quarantine. Family members lived in complex situations during the pandemic, which increased the risk of overexposure by increasing the levels of stress, anxiety, and instability. The increase in domestic violence during the pandemic is reported in many countries, such as China, Brazil, the United States, and Italy, which may represent as “tip of the iceberg” since many victims do not have the freedom to report the abuse ( Campbell, 2020 ). Domestic violence is reported as physical harm, emotional harm, and abuse. Intimate partner violence is a common form of family violence during the COVID-19 pandemic ( Kaukinen, 2020 ; Zhang, 2020 ). There are three factors of family violence, such as the opportunities of family violence during lockdown and isolation at home, the economic crisis in the households, and insufficient social support for the victims of domestic violence ( Zhang, 2020 ). Individual resilience is a strong predictor of the willingness of people to cope with emergencies and challenges of different kinds, including the COVID-19 pandemic ( Kimhi et al., 2020 ). Individual resilience and well-being are significant factors influencing distress symptoms and a sense of danger ( Kimhi et al., 2020 ). Physical abuse, emotional abuse, and stalking are kinds of intimate partner violence that are experienced by some women during the COVID-19 quarantine ( Mazza et al., 2020 ).

Family violence is one of the causes of divorce. Family violence has become a serious social problem. During the pandemic in China, some couples decide to divorce due to family violence in their spousal relationship ( Zhang, 2020 ). Divorcing partners in the wake of COVID-19 have more complex issues because they should physically and emotionally separate in their households. It is suggested to involve family therapy so they can share their problems that arise readily to prevent anger, contempt, and other problematic conflicts ( Lebow, 2020b ). A good cooperation and communication among divorced parents may help children achieve their goals through this hard time. A recent study found that communication between two single parents discussing the impact of the COVID-19 epidemic on their family life could acquire something considerably more significant than just support and self-discovery ( Abdellatif & Gatto, 2020 ).

Financial distress, economic depression, unemployment, poverty, and added stressors such as the care and homeschooling of children, social distancing, and family isolation have increased the opportunities for family violence ( Kaukinen, 2020 ; Zhang, 2020 ). Family members with lower financial income, lower education status, and lower occupational status are more likely to experience family violence, including family conflicts, economic distress, high tension, lower mental well-being, and insufficient support during physical distancing or lockdown ( Zhang, 2020 ). Families have been dealing with threats from COVID-19 pandemics, both direct and indirect effects ( Lebow, 2020a ). The direct effects are the loss of family members, anxiety feelings related to family loss, increased unemployment, limited physical and social contact, family stress, conflict, and financial vulnerability. During the pandemic, families may have a virtual connection to maintain their communication. Therefore, geographic challenges are becoming less important due to virtual interconnection. Furthermore, a recent study found that virtual communication during the COVID-19 pandemic could improve family well-being and happiness ( Gong et al., 2021 ). At this time, digital technology, which needs digital literacy, becomes essential ( Hitchings & Maclean, 2020 ).

The coronavirus pandemic has increased the risk of mental health problems (such as mood disorders, fear, anxiety, depression, alcohol and smoking abuse) as well as physical health problems (such as sleep disturbance, gastrointestinal problems, poorer health condition) ( Mazza et al., 2020 ). The mental problems are caused by work stress, financial stress, and changes in the social life. The coronavirus pandemic has increased the risk of mental disorders (such as mood disorders, anger, anxiety, depression, alcohol and smoking abuse) as well as physical disorders (such as sleep disturbance, gastrointestinal problems, poorer health condition). Children’s health and well-being are also in danger during the pandemic, because most of the children may get the transmission of the virus from their adult family members who were previously infected ( Su et al., 2020 ). Therefore, individual resilience and well-being as a part of family resilience and well-being should be maintained to cope with the threat of the coronavirus pandemic.

Homeschooling during the pandemic makes parental responsibilities extended to include being teachers, coaches, trainers, and mentors for their children's school from home and other extracurricular activities ( Lebow, 2020b ). The condition of staying at home may increase parental stressors, particularly for working parents who are responsible for their multi-task dealing with other stressful conditions as paid workers and also doing domestic tasks. Moreover, violence may increase among children during homeschooling. During this time, parents and children are similarly living with stress, fear, and many challenges because they share their activities in the same place for uncertain time. Some factors influence the home learning as a distance learning, such as poverty, the educational levels of parents, mental health, the availability of gadget, and Internet access. During the pandemic, however, parental involvement in their children's activities provided an opportunity to develop and preserve family well-being ( Evans et al., 2020 ).

During the pandemic, it should be more widely focused on helping family members generate their individual space. A good and intensive family communication is needed to deal with the uncertainty of the COVID-19 pandemic. Some interventions are needed to improve maternal and child health and nutrition, such as strengthening the food supply chain, reducing food insecurity, building a net social security program, and a cash support program for the disadvantaged families during the COVID-19 pandemic. Based on the literature review, it is recommended to increase public awareness to staying connected and reporting if they find any family violence. Improving the readiness and knowledge of healthcare providers and counselors is needed to provide counseling services to help families who have physical and mental health problems. Fulfilling parents with updated information and guidance is important to deal with pandemic especially how to have working life balance and quality of life between working, guiding children in their homeschooling and other activities. Providing parenting resources during COVID-19 including conflict management is needed to have positive relationship and manage parenting stress. The government should take action to mitigate the social, economic, and health impacts of the pandemic on families, especially those who are vulnerable to losing household income. During the pandemic, it is important to maintain family well-being by staying connected with communication, managing conflict, and making quality time within family. Promoting family resilience through shared beliefs and close relationships within families is needed during the COVID-19 pandemic.

This study has some limitations. The limitation of this article is the possibility of omission of the potential article related to the family welfare during the COVID-19 pandemic. Moreover, the exclusion of unpublished articles will become another limitation. The findings of this literature review were mostly conducted in higher-income countries, which limits the generalization of the findings to low- and middle-income countries. The future research is required regarding family welfare as responses to women’s empowerment during the COVID-19 pandemic with homogenous family’s samples or with a large sample size with heterogeneity of welfare's status. The future research can be conducted by mixed methods between qualitative and quantitative methods.

COVID-19 outbreak around the world has become a public health concern. The coronavirus pandemic has had a substantial impact on the family's life. Physical and mental health problems, economic instability, and family violence are social issues during the pandemic that should be dealt with. The government should take action to mitigate the social, economic, and health impacts of the pandemic on families especially those who are vulnerable to losing household income. Promoting family welfare and resilience through shared beliefs and close relationships within families is needed during the COVID-19 pandemic.

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

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs: Maria Gayatri https://orcid.org/0000-0002-2792-5586

Mardiana Dwi Puspitasari https://orcid.org/0000-0002-6827-3350

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IMAGES

  1. ≫ Nationalism and Covid-19 Pandemic Free Essay Sample on Samploon.com

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  2. Beyond COVID-19: A Whole of Health Look at Impacts During the Pandemic

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  3. Examining COVID-19 versus previous pandemics

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  4. COVID-19

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  5. "COVID-19 PR Reflection" by Madeline Dingle

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  6. COVID-19 Affects Everyone but Not Equally : The Gendered Poverty

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COMMENTS

  1. A critical analysis of the impacts of COVID-19 on the global economy and ecosystems and opportunities for circular economy strategies

    As shown in the methodological framework in Fig. 1, the paper starts with a brief review of the impacts of historical plagues to shed more light on the link between the past and the unprecedented time, which then led to an overview of the positive and negative impacts of COVID-19. The role of CE as a vehicle for constructive change in the light ...

  2. Coronavirus disease (COVID-19) pandemic: an overview of systematic

    Navigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic. Nine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of ...

  3. The Lancet Commission on lessons for the future from the COVID-19 pandemic

    As of May 31, 2022, there were 6·9 million reported deaths and 17·2 million estimated deaths from COVID-19, as reported by the Institute for Health Metrics and Evaluation (IHME; throughout the report, we rely on IHME estimates of infections and deaths; note that the IHME gives an estimated range, and we refer to the mean estimate). This staggering death toll is both a profound tragedy and a ...

  4. Report of the Independent Panel for Pandemic Preparedness and Response

    In May, 2020, with COVID-19 affecting just about every country on the planet, the World Health Assembly requested the WHO Director-General to initiate an independent, impartial, and comprehensive review of the international health response to the pandemic. He asked us to convene an independent panel for this purpose. The members of the Independent Panel for Pandemic Preparedness and Response ...

  5. Opinion

    The journal Cell recently published a paper on pandemic diseases and how Covid-19 has come upon us, by a scientist named Dr. David M. Morens and one co-author. Dr. Morens, a prolific author and ...

  6. Mental Health and the Covid-19 Pandemic

    Mental health professionals can help craft messages to be delivered by trusted leaders. 4. The Covid-19 pandemic has alarming implications for individual and collective health and emotional and ...

  7. Frontiers

    Rahn et al. offer a comparative view of compliance and risk perception, examining three hazard types: COVID-19 pandemic, violent acts, and severe weather. With a sample of 403 Germans (age range: 18-89 years, 72% female), they studied how age, gender, previous hazard experience and different components of risk appraisal (perceived severity ...

  8. What Covid Has Taught the World about Ethics

    Research is a duty for health professionals and in the best interest of patients in times of a pandemic: Empirical exploration and ethical implications of the Research Ethics in Times of Pandemic ...

  9. Consequences of the Coronavirus disease 2019 pandemic on child and

    This pandemic has had a wide range of impacts on children and adolescents, making it an excellent topic for a scoping review (Panchal et al., 2021).With pre-print and peer-reviewed publications on COVID-19 becoming rapidly available, this living approach was timely to identify emerging literature (Ioannidis et al., 2021).Additionally, an interactive evidence map (IEM) is an intuitive and ...

  10. The pandemic bookshelf grows

    The Pandemic Century: A History of Global Contagion from the Spanish Flu to Covid-19 Mark Honigsbaum WH Allen (2020) The Plague Cycle: The Unending War Between Humanity and Infectious Disease ...

  11. A Critique of Coronavirus

    A Critique of Coronavirus. Volume 26, Number 7—July 2020. Article Views: 10965. Data is collected weekly and does not include downloads and attachments. View data is from . Time period. Altmetrics. Click a source for Altmetric details. What is the Altmetric Attention Score? The Altmetric Attention Score for a research output provides an ...

  12. Public opinion concerning governments' response to the COVID-19 pandemic

    The papers mentioned above do not consider one crucial factor, political partisanship, when dealing with government approval issues regarding the COVID-19 pandemic. [ 5 - 7 ] pay attention to partisan differences in U.S. respondents' views over the COVID-19 pandemic, but their results limit individual behavior and beliefs about the pandemic ...

  13. Assessing COVID-19 pandemic policies and behaviours and their economic

    COVID-19 magnified the polarisation and persistent social, economic, and racial inequities that already existed across US society, but the next pandemic threat need not do the same. US states that mitigated those structural inequalities, deployed science-based interventions such as vaccination and targeted vaccine mandates, and promoted their adoption across society were able to match the best ...

  14. The Covid-19 Pandemic

    Four years later, the shadow of the pandemic continues to play a profound role in voters' pessimism and distrust amid a presidential rematch. By Lisa Lerer, Jennifer Medina and Reid J. Epstein.

  15. Impact of COVID-19 on people's livelihoods, their health and our food

    Reading time: 3 min (864 words) The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an unprecedented challenge to public health, food systems and the world of work. The economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty ...

  16. Research Roundup: How the Pandemic Changed Management

    To understand such changes, we recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic. These papers were published between March 2020 and July 2023 in top ...

  17. How a Pandemic Malaise Is Shaping American Politics

    The pandemic hardened voter distrust in government, a sentiment Mr. Trump and his allies are using to their advantage. Fears of political violence, even civil war , are at record highs, and ...

  18. Older adults' experiences during the COVID-19 pandemic: a qualitative

    Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult's experiences during the pandemic. This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory.

  19. Impact of COVID-19 outbreak on the mental health in sports: a review

    Global pandemic, lockdown restrictions, and COVID-19 compulsory social isolation guidelines have raised unprecedented mental health in the sports community. The COVID-19 pandemic is found to affect the mental health of the population. In critical situations, health authorities and sports communities must identify their priorities and make plans to maintain athletes' health and athletic ...

  20. COVID-19: Crisis, Critique, and the Limits of What We Can Hear

    Biopolitical Economies of the COVID-19 Pandemic by Jon Short. 4. On Ways of Living in the Midst of the COVID-19 Global Pandemic (Three Brief Meditations) by John Paul Ricco. 5. Crisis, Critique, and the Limits of What We Can Hear by Stuart J. Murray. 6. The Pandemic is (Extra) Ordinary by Penelope Ironstone. 7. The Biopolitics of Numbers by ...

  21. Influenza Health Worker Vaccination Programmes: Platforms for Pandemic

    Pandemic preparedness: In Thailand, using existing influenza vaccine management strategies and structures enabled the country to quickly reach high coverage rates for COVID-19 vaccination as soon as the COVID-19 vaccine supply was sufficient. References [i]. Table 4: Summary of WHO position papers - immunization of health care workers.

  22. The Impact of COVID-19 Pandemic on Family Well-Being: A Literature Review

    The aim of this study is to analyze the previous studies in relation to family well-being during the COVID-19 pandemic. Methods: A literature review was conducted on PubMed, Medline, Web of Science, and Scopus for studies using a cross-sectional or quasi-experimental design published from their inception to October 15, 2020, using the keywords ...