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

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  • 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%.


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.


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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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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Israel Júnior Borges do Nascimento & Milena Soriano Marcolino

Medical College of Wisconsin, Milwaukee, WI, USA

Israel Júnior Borges do Nascimento

Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, College of Nursing, The Ohio State University, Columbus, OH, USA

Dónal P. O’Mathúna

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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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Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review

  • Suzannah Stuijfzand 1 ,
  • Camille Deforges 1 ,
  • Vania Sandoz 1 ,
  • Consuela-Thais Sajin 1 ,
  • Cecile Jaques 2 ,
  • Jolanda Elmers 2 &
  • Antje Horsch   ORCID: orcid.org/0000-0002-9950-9661 1 , 3  

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Epidemics or pandemics, such as the current Coronavirus Disease 2019 (COVID-19) crisis, pose unique challenges to healthcare professionals (HCPs). Caring for patients during an epidemic/pandemic may impact negatively on the mental health of HCPs. There is a lack of evidence-based advice on what would be effective in mitigating this impact. Objectives: This rapid review synthesizes the evidence on the psychological impact of pandemics/epidemics on the mental health of HCPs, what factors predict this impact, and the evidence of prevention/intervention strategies to reduce this impact.

According to rapid review guidelines, systematic searches were carried out in Embase.com , PubMed, APA PsycINFO-Ovid SP, and Web of Science (core collection). Searches were restricted to the years 2003 or later to ensure inclusion of the most recent epidemic/pandemics, such as Severe Acute Respiratory Syndrome (SARS). Papers written in French or English, published in peer-reviewed journals, and of quantitative design using validated measures of mental health outcomes were included. Of 1308 papers found, 50 were included. The full protocol for this rapid review was registered with Prospero ( reg.no. CRD42020175985).

Results show that exposed HCPs working with patients during an epidemic/pandemic are at heightened risk of mental health problems in the short and longer term, particularly: psychological distress, insomnia, alcohol/drug misuse, and symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, burnout, anger, and higher perceived stress. These mental health problems are predicted by organizational, social, personal, and psychological factors and may interfere with the quality of patient care. Few evidence-based early interventions exist so far.

HCPs need to be provided with psychosocial support to protect their mental wellbeing if they are to continue to provide high quality patient care. Several recommendations relevant during and after an epidemic/pandemic, such as COVID-19, and in preparation for a future outbreak, are proposed.

Peer Review reports

Epidemics or pandemics, such as the current COVID-19 crisis, pose a significant threat to public health. This sudden outbreak of a novel, highly contagious disease, is unpredictable and associated with high morbidity and mortality rates [ 1 ]. An epidemic (or outbreak) is the “occurrence in a community or region of cases of an illness … clearly in excess of normal expectancy” [ 2 ] , p. 3, and a pandemic (or large scale outbreak) is “a large epidemic”, “best reserved for infectious diseases.” [ 3 ] , p.1020. Compared to other large-scale disasters, epidemics/pandemics pose unique challenges to HCPs, as the treatment course is often yet unknown, social isolation is required following presentation of first symptoms, and frontline HCPs not only fear for the safety of their patients, but also for their own health, and that of their close family members. Furthermore, many HCPs are suddenly required to carry out unfamiliar tasks in an unfamiliar area of care, such as high-risk, high-intensity units, all of which are likely to be associated with elevated levels of psychological distress [ 4 ]. These characteristics of an outbreak reduce the availability of social support, including support from their colleagues and their family, which is known to buffer the negative impact of stress [ 4 ].

Why is this review needed?

Caring for patients during an epidemic/pandemic may impact negatively on the mental health of HCPs [ 5 , 6 ]. While studies on this impact exist, this literature has yet to be updated and fully synthesized alongside a review of potential risk and protective factors. Understanding this mental health impact would sensitize policy makers and governance bodies about the importance of considering the mental health needs of HCPs in the preparations for, during, and in the aftermath of such outbreaks. Furthermore, there is a lack of evidence-based advice on what would be effective in mitigating this impact, calling for a synthesis of the evidence on prevention/intervention strategies.

We therefore conducted a rapid review on the psychological impact of pandemics/epidemics on the mental health of HCPs, what factors may protect or increase the risk of this impact and what evidence there is for prevention/intervention strategies to reduce this impact.

The full protocol for this rapid review was registered with Prospero ( reg.no. CRD42020175985). A rapid review is defined as a form of synthesis that streamlines or omits methods for a systematic review in order to produce evidence for stakeholders [ 7 ]. Therefore, the number of reviewers conducting each phase of the screening differed from that of a traditional systematic review and no formal study quality evaluation took place (see C Garritty, G Gartlehner, C Kamel, V King, B Nussbaumer-Streit, A Stevens, C Hamel and L Affengruber [ 7 ] for guidelines). However, a rapid review was deemed the method of choice in order to support decision makers in a timely manner on how the mental health of their HCPs during the current COVID-19 crisis can be protected.

Search strategy and selection criteria

Following rapid review guidelines C Garritty, G Gartlehner, C Kamel, V King, B Nussbaumer-Streit, A Stevens, C Hamel and L Affengruber [ 7 ], systematic searches were carried out on the 22nd March 2020 on the databases Embase.com , PubMed, APA PsycINFO - Ovid SP, Web of Science (core collection). An additional search was performed in Google Scholar, followed by citation tracking of included studies. Searches were restricted to the years 2003 or later, ensuring inclusion of the most recent epidemic/pandemics, such as SARS. The search was based on a combination of terms related to “healthcare professional” (e.g., “healthcare provider”), “disease outbreak” (e.g., “pandemic”) and “mental health” (e.g., “depression”). It included (but was not limited to) the following epidemics/pandemics that occurred from 2003 onwards: COVID-19, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza pandemic (H1N1), avian influenza (H5N1), and West Nile Fever (see Supplementary Materials: Additional file 1 for the full search algorithms).

For inclusion, papers had to be written in French or English, published in peer-reviewed journals, and present quantitative data including validated measures of mental health outcomes. Measures were judged to be valid if there was psychometric information available confirming their validity and reliability. Modified versions of validated measures were accepted if the modification entailed adapted instructions for a specific scenario/trauma/population. Intervention studies were included if the design allowed the assessment of the effectiveness of the intervention on mental health outcomes. Studies were included when HCPs worked directly with infected/suspected patients in hospitals or in communities during the outbreak (exposed). Mixed methods studies were included if quantitative data could be separated from qualitative date. Studies did not have to contain a control group for inclusion. Conference abstracts, opinion pieces, editorials, and letters were excluded, as were (reviews of) qualitative studies. Titles, abstracts and then full texts were screened by two researchers. Where the researchers were unsure of eligibility, the paper was passed through to the next phase of screening to allow further scrutiny. For each accepted article after full-text screening, two researchers carried out data extraction at different times, and a third one checked for and resolved any discrepancies. All journals of accepted papers were verified as being peer-reviewed journals through Ulrich’s Global Serials Directory, or on the website of the journal by a specialist librarian.

Figure  1 depicts the screening and eligibility checking process and details the numbers of papers included and excluded at each phase, including reasons for exclusion for the full-text screening phase. As can be seen in Fig.  1 , of 1308 papers found, 50 were included in this review. The characteristics of studies that met our inclusion criteria are presented in Table  1 . Across the manuscript, as in Table  1 , long-term effects are those reported in study as measured 6 months or longer after the outbreak.

figure 1

Prisma flowchart of Study Selection

From the included papers, two systematic reviews were identified that directly contributed to the research questions. One reviewed the evidence of the impact of past outbreaks on the mental health of HCPs [ 5 ] and one reviewed the evidence for organizational and social predictors of the impact of past outbreaks on the mental health of HCPS [ 6 ]. Therefore, a summary of these systematic reviews are a focal part of this rapid review. Of the 50 accepted papers for this rapid review, 21 were included in the review of Vyas et al. [ 5 ] and 16 were included in the review of Brooks et al. [ 6 ], ten appeared in both (see Table 1 ). Beyond the systematic reviews, data extracted from primary studies are included in this rapid review if they are more recent than the search dates of the systematic reviews, report on mental health outcomes not covered by the first systematic review, or investigated predictors of mental health outcomes not included in the second systematic review.

The psychological impact of an epidemic/pandemic on the mental health of healthcare professionals

A systematic review and meta-analysis [ 5 ] (including studies from 2000 to 2014) showed an impact of an epidemic/pandemic on the mental health of HCPs. This review included studies using both diagnostic tools and self-report measures with clinical cut-offs to assess mental health outcomes. Therefore, percentage prevalence’s are best interpreted as ‘probable’ percentage of cases. Effect sizes (standardised mean difference) reflect the difference between an exposed HCPs group and a control group. Thus, where a positive effect is reported, the exposed group showed higher symptom scores than the control group. In this review, psychological distress was assessed in 13 studies, with an average rate among exposed HCPs of approximately 40% (range: 11–75%). Insomnia was assessed in four studies, with an average rate among exposed HCPs of approximately 39% (range: 30–52%). Alcohol and drug misuse were assessed in five studies, with an average rate of approximately 13% (range: 6–21%). Posttraumatic stress disorder (PTSD) symptoms were assessed in 19 studies, with an average rate of approximately 21% (range: 10–33%), of whom 40% reported persistently high PTSD symptoms 3 years after exposure. Meta-analytic results showed effects were small, (SMD = 0.12, 95% CI = − 0.23 to 0.47) but not significant. Depression symptoms were measured in eight studies, with an average rate of approximately 46% (range: 23–74%), of whom up to 9% reported severe levels. 11% were clinically diagnosed 1 month after the disease outbreak. Meta-analytic results showed effects were moderate (SMD = 0.40, 95% CI = 0.24–0.51) and significant. Anxiety symptoms were assessed in fourteen studies. The average rate was approximately 45% (range: 19–77%). Meta-analytic results showed effects were small, (SMD = 0.08, 95% CI = − 0.09 to 0.25) and not significant.

Further mental health outcomes were reviewed that had not been included in Vyas et al. [ 5 ] or more recent papers (2015–2020) containing more data on the same outcomes. Table  2 contains all data related to the mentioned relationships. Burnout symptoms were assessed by five studies [ 14 , 17 , 29 , 32 , 37 ]. It should be noted that the sample of Z Marjanovic, ER Greenglass and S Coffey [ 29 ] is the same sample as L Fiksenbaum, Z Marjanovic, ER Greenglass and S Coffey [ 14 ]. Burnout symptoms during the outbreak were shown to be correlated with exposure [ 14 ], were significantly higher in HCPs exposed to the outbreak than in non-exposed HCPs [ 17 , 37 ], and were predicted by exposure (vs non-exposure) [ 29 ]. The difference between exposed and non-exposed groups were significant over a year after the outbreak [ 32 ] and also impacted on HCPs’ ability to work. Indeed, exposed HCPs were more likely than non-exposed HCPS to work reduced hours and have more sickness absence [ 32 ], but also to show avoidant behaviour toward patients [ 29 ]. Across these five studies, there is thus accumulating evidence of the impact of an epidemic/pandemic on burnout symptoms during the outbreak, with some evidence of a long-term effects, and detrimental patient care-related behaviours during and after the outbreak.

Two studies [ 14 , 29 ] investigated state anger within the same sample. L Fiksenbaum, Z Marjanovic, ER Greenglass and S Coffey [ 14 ] showed that caring for infected patients was correlated with increased levels of state anger in HCPs during the outbreak. Z Marjanovic, ER Greenglass and S Coffey [ 29 ] found that exposure (vs non-exposure) did not predict state anger but the latter was correlated with avoidant behaviour towards patients during the outbreak. As results pertain to the same sample, evidence for an impact on state anger is weak.

Five studies [ 13 , 20 , 33 , 35 , 48 ] investigated levels of perceived stress . Two studies found that during the outbreak, perceived stress levels of exposed HCPs were higher than a normative value [ 13 , 33 ], whereas two studies showed perceived stress was no different between exposed and non-exposed HCPs [ 20 , 33 ]. However, a year following the outbreak, perceived stress was higher amongst exposed vs non-exposed HCPs and had increased over time [ 33 ]. In addition, a year following the outbreak, perceived stress was higher amongst HCPs vs non-HCPs and had increased over time for HCPs only [ 20 ]. Evidence also indicates that during a pandemic, perceived stress was a mediator between social support and sleep quality [ 48 ] and between hardiness (resilience) and stigma, respectively, and mental health [ 35 ].

Two studies [ 38 , 46 ] investigated coping strategies during an epidemic/pandemic. One showed that, during an outbreak, HCPs with psychiatric or PTSD symptoms used maladaptive coping strategies compared with those without symptoms [ 38 ]. It should be noted that there was no difference between exposed vs non-exposed HCPs on psychiatric or PTSD symptoms [ 38 ]. Furthermore, without a pre- outbreak measure, it is unclear whether all staff were equally affected and there is thus no evidence of the effect of the outbreak. However, the size of the non-exposed sample was double that of the exposed group, raising questions of power for that test. The second study showed that during an outbreak, different groups of HCPs used different coping strategies (see Table 2 ) [ 55 ]. Authors stated that the sample had been exposed to the infection; however, without a comparison group or ‘pre-outbreak’ measure, it is unclear whether the use of coping strategies was affected by the outbreak. These two studies suggest that during an outbreak, HCPs may engage in maladaptive coping strategies, however, it is unclear whether use of these strategies increased due to an outbreak.

One study [ 28 ] investigating the long-term effects of an outbreak on PTSD symptoms found that infected HCPs had significantly higher rates of chronic PTSD (30 months post SARS) than infected non-HCPs.

One further small study found that 2% of healthcare professionals with no psychiatric history before the outbreak had a new DSM-IV axis 1 mental disorder within 1 year after the outbreak [ 19 ]. Further research found no differences in symptoms of generalised anxiety disorder assessed during the outbreak between internal medicine staff, Ebola patient treatment staff, and research laboratory staff [ 22 ]. Another study found Chinese HCPs’ symptoms of obsession-compulsion, depression, hostility, paranoid ideation, and psychoticism did not change from 1 week after arrival in an infected zone in Sierra Leone to 1 week after leaving. This may perhaps be explained by the fact that these HCPs were not in their own country and thus perhaps not subject to the same worries of going home and infecting families, as local staff [ 16 ]. Furthermore, when considering symptoms of obsessive compulsion, it should be noted that many of the behaviours considered symptoms may be ‘normal’ in times of an epidemic/pandemic, e.g., frequent washing of hands.

In conclusion, healthcare professionals exposed to working with patients during the COVID-19 outbreak may be at heightened risk of mental health problems, particularly, psychological distress, insomnia, alcohol/drug misuse, and symptoms of PTSD, depression, anxiety, burnout, anger, higher perceived stress, and are more likely to engage in maladaptive coping strategies.

Predictors of psychological impact an of epidemic/pandemic on the mental health of healthcare professionals

The next section of this rapid review focuses on synthesizing the evidence on protective or risk factors with a view to informing recommendations for prevention and intervention. One systematic review synthesizing the social and occupational factors affecting the mental health of HCPs covered the literature up to 2015 and included 22 studies [ 6 ], all of which had investigated the SARS epidemic. SK Brooks, R Dunn, R Amlôt, GJ Rubin and N Greenberg [ 6 ] identified six organizational and four social factors as showing an influence on mental health outcomes. For this rapid review, no further evidence of social and organizational factors published after 2015 was identified amongst our accepted papers. Below is a brief summary of the organizational and social factors found by Brooks et al. [ 6 ] and associated data can be found in [ 6 ]. Further predictors, beyond organizational and social factors, may also influence the impact of epidemics/pandemics on mental health. Therefore, evidence for further protective and risk factors was extracted from other primary studies accepted for this rapid review. Thirteen papers were identified. Further predictors were classified as Psychological factors or Personal factors .

Organizational predictors [ 6 ]

Occupational role influenced mental health in HCPs, with those in direct contact with infected patients showing the poorest psychological outcomes. Nurses had poorer outcomes than doctors. Specialized training and preparedness showed as a protective factor against stress and anxiety. However, where training was perceived as inadequate, HCPs were more likely to experience symptoms of burnout and PTSD, and their symptoms often continued in the longer term. High-risk environments (i.e., a high risk of exposure to infected patients) were associated with higher symptoms of anxiety, stress, PTSD, alcohol consumption, burnout, and sleep problems. Being in quarantine was associated with higher symptoms of acute stress disorder, PTSD, and alcohol intake. The longer the quarantine, the greater an adverse effect was found on anger symptoms and avoidance behaviors.

Job stress, in particular where one’s ability to do one’s job was compromised, lack of control of one’s job, and being involuntary deployed to work with infected patients negatively influenced mental health outcomes. For example, those who had to involuntarily care for infected patients reported higher levels of anxiety and depression symptoms than volunteers. Perceptions of safety threat and risk was identified as a protective and a risk factor for mental health. Feelings of trust in equipment and infection control procedures predicted lower emotional exhaustion and state anger. Belief in the precautionary measures within the workplace decreased concerns. However, high perception of personal risk predicted PTSD symptoms.

Social predictors [ 6 ]

In the context of an epidemic/pandemic, organizational support and family/friends support can function as protective factors when at adequate levels. However, low levels or inadequate organizational support, inclusive of psychological support and inadequate insurance/compensation, were risk factors for mental health. Social rejection or isolation was associated with poorer mental health outcomes. HCPs who experienced an impact on life (e.g., reduced contact with family) due to the outbreak showed greater mental health problems.

Personal predictors

Some personal characteristics were found to increase the risk of mental health problems of HCPs during an epidemic/pandemic . Those who were single were 1.4 times more likely to have minor psychiatric disorders according to a clinical cut-off (95% CI  = 1.02–2.0, p  = .048) during an outbreak. However, there was no test of whether this differed between exposed and non-exposed HCPs [ 8 ]. Being single was also found to be predictive of higher depressive symptoms ( AOR  = 4.35, 95% CI  = 1.65–11.42; p  = .0029) amongst hospital staff during an outbreak, though this test did not separate exposed from non-exposed HCPs [ 25 ]. Being single was also cited in the systematic review of [ 5 ] as being predictive of higher symptoms of psychological distress, higher depressive symptoms, and persistent PTSD symptoms. However, in one study by K Sim, PN Chong, YH Chan and WS Soon [ 38 ], being married was predictive of the presence of PTSD symptoms ( OR  = 11.43, CI  = 1.41 to 100, p  = .02). In another study, higher PTSD symptoms were found amongst those who lived in a dormitory or away from their family ( M  = 37.2, SD  = 20.2) than those living with family ( M  = 33.6 SD  = 19.5.5; p  < .005) [ 12 ]. During an outbreak, more nurses who perceived stress (50.7%) additionally reported average or poor physical health than those who reported no stress (18.4%, p  = .001) [ 9 ]. Less healthcare work experience predicted higher psychological distress symptoms in exposed HCPs ( β  = −.26, t  = − 3.28, p  = .001) [ 32 ]. Being a healthcare professional with a younger age [ 38 ] predicted the presence of PTSD symptoms during an outbreak ( OR  = .94, CI  = 0.89 to 0.98, p  = .007). KJ Vyas, EM Delaney, JA Webb-Murphy and SL Johnston [ 5 ] in their systematic review also identified a younger age as predictive of symptoms of anxiety, depression and PTSD, and identified less healthcare experience as a predictor of symptoms of psychological distress, and PTSD. KJ Vyas, EM Delaney, JA Webb-Murphy and SL Johnston [ 5 ] also reported that HCPs with a lower household income reported higher PTSD symptoms during an outbreak. Finally, experiencing stigma (social rejection, prejudice, or discrimination due to their work) as HCPs during the outbreak predicted concurrent mental health symptoms ( β  = − 0.306, t  = − 7.2376, p  < 0.001). This relationship was found to be mediated by perceived stress (indirect effect = − 0.061, Boot SE = 0.020) [ 35 ].

Psychological predictors

Resilience (hardiness) is a potential protective factor and was found to have both a direct and an indirect influence on mental health during an outbreak [ 35 ]. A higher resilience score directly predicted better mental health in exposed HCPs ( β  = 0.49, t  = 4.87, p  < 0.001). Indirectly, hardiness, was associated with decreased stress perception, and this in turn was associated with better mental health (indirect effect = 0.251, Boot SE = 0.638) [ 35 ]. Maladaptive coping was a risk factor, with long-term predictive effects found on symptoms of burnout ( β  = 0.29, t  = 3.34, p  = 0.001), PTSD ( β  = 0.31, t  = 3.78, p  < 0.001), and psychological distress ( β  = 0.37, t  = 4.39, p  < 0.001) [ 32 ]. Fatigue (physical and mental) predicted symptoms of poor mental ( B  = − 0.30, SE  = 0.12, p  = .012) and physical ( B  = − 0.53, SE  = 0.11, p  < .001) health during an outbreak, alongside perceived lack of knowledge of the infection [ 22 ]. Furthermore, having a negative emotional experience of the outbreak predicted an increased likelihood of PTSD amongst HCPs (β = .17, p  < .01). In this study, authors state negative emotional experience influenced PTSD symptoms of non-HCPs more than HCPs, while perceived risk (of infection) affected HCPs more than non-HCPs. However, how the statistical difference in magnitude of the coefficient was carried out was unclear [ 39 ]. More HCPs showing a new onset psychiatric disorder in the long term following an outbreak had a psychiatric disorder before the outbreak (18%) than those without a new onset (2%; p  = .03) [ 19 ].

Evidence for the psychological and personal factors identified in this review comes from one or two studies, suggesting preliminary rather than strong evidence. It is also not yet clear which of these factors is the most important. This preliminary evidence points towards identifying those at risk, who may benefit from prevention/intervention programs, and what preventions/intervention may wish to target to influence mental health of HCPs.

What can be done to prevent or reduce the impact of an epidemic/pandemic on the mental health of healthcare professionals?

Intervention programs.

Five studies [ 49 , 50 , 51 , 52 , 53 ] investigating the effect of preventative programs or interventions addressing mental health outcomes in HCPs were included (see Table 1 for more details about the content of the intervention and the study design). Regarding the preventative programs, the SARS prevention program addressed organizational, patient-care and psychological issues before HCPs saw the first infected patients and lead to an improvement in anxiety and depression symptoms, as well as sleep quality [ 49 ]. In another study, two computerised simulation sessions of real-life events linked to caring for infected patients resulted in lower state anxiety symptoms [ 50 ]. A pilot randomized controlled trial (RCT) testing varying lengths (1.75 h, 3 h and 4.5 h) of a computer-assisted resilience training (interactive reflective exercises) before the disease outbreak resulted in improved coping strategies (problem-solving and seeking support), with the medium length being optimal [ 51 ].

Regarding early intervention programs in the acute aftermath of the outbreak, a one-day psychological first aid training did not lead to improved professional quality of life (burnout and compassion fatigue) [ 52 ]. However, a stepped intervention introduced towards the end of the outbreak led to a decrease in symptoms of PTSD, depression, anxiety, anger, as well as perceived stress and relationship problems, and an improvement in sleep [ 53 ]. This early intervention program consisted firstly, of a two-hour workshop on psychological first aid, after which improvement in mental health symptoms was assessed. If individuals needed more, a two-hour workshop on psychoeducation was offered and again, improvement in their symptoms was evaluated. If more help was needed, then six weekly sessions of a brief cognitive behavioral therapy (CBT) group program were offered. Of note: HCPs were trained by mental health experts to carry out this stepped approach for their peers.


Please note that the following recommendations are based on the evidence of risk and protective factors, as well as intervention studies identified by this review. It is worth noting, that those based on risk and protective factors have not yet been tested for effectiveness.

Before the disease outbreak

An infectious disease prevention program should be put into place by individual health services but coordinated at an international level. Important elements of the program are training of HCPs, planning and allocation of staff, provision of sufficient protective equipment, and establishment of a mental health team for professionals [ 49 ]. This may also include computerized simulation training of patient care during an outbreak [ 50 ] and a computer-assisted resilience training consisting of interactive reflective exercises [ 51 ].

During the disease outbreak

Given the likely increase of mental health problems among HCPs, widespread screening to identify those in need of support should be carried out, as the increased stress and burden, as well as stigma experienced by HCPs may make it hard for them to actively seek help [ 35 ]. Based on the evidence of risk factors, the following groups may be in particular need of psychological support: HCPs having direct contact with infected patients [ 6 ], those that are involuntary deployed to work with infected patients [ 6 ], those with less healthcare work experience [ 5 , 32 ], individuals who are single, or do not currently live with family [ 12 , 25 ], of younger age [ 5 , 32 ], and those with a lower household income [ 5 ]. Comparing different groups of HCPs, those who spent time in quarantine should be prioritized [ 6 , 25 ].

A widespread educational campaign alerting HCPs to the possibility of experiencing mental health problems may also help to make those in need come forward for help, as well as fight the potential stigma often associated with mental health problems [ 35 ]. Assessment of a wide range of mental health outcomes and psychological distress linked to the disease outbreak [ 6 ] is recommended, particularly symptoms of insomnia, alcohol/drug misuse, PTSD, depression, anxiety, burnout, anger, and perceived stress [ 5 , 32 , 33 ]. For those reporting mental health problems, a three-phased stepped intervention consisting of a workshop on psychological first aid, a workshop on psychoeducation, and a brief CBT group program may be helpful [ 53 ]. In order to increase access, this intervention could be carried out by generic healthcare professionals (peers) trained by mental health specialists [ 53 ].

With regards to organizational factors, managers should increase organizational support and foster peer support [ 6 ]. HCPs should be encouraged to volunteer for working with infected patients [ 6 ], rather than be deployed. Managers should regularly provide updated information about the epidemic/pandemic and how HCPs can best protect themselves [ 6 ]. Adequate specialized training should be made available [ 6 , 32 ], with personal infection control as a priority [ 6 , 9 ].

After the disease outbreak

HCPs’ perceived risk should be screened within a few months after the disease outbreak, as this is a risk factor for mental health and occupational problems over 1 year after the outbreak [ 32 ].

By conducting this rapid review, we have brought together into one place: the evidence on the impact of pandemics/epidemics on the mental health of HCPs, the evidence of influencing factors on the impact pandemics/epidemics on the mental health of HCPs, and evidence on prevention/interventions to mitigate this impact. Furthermore, we have updated a previous review [ 5 ] and broadened the set of mental health outcomes. We bring an additional 10 primary studies beyond those found in the systematic reviews and an additional three papers on interventions. Previously, evidence on social and organizational risk factors had been synthesized [ 6 ] and this rapid review adds evidence on psychological and personal risk factors.

Results from this rapid review suggest that HCPs may experience an adverse impact on their mental health during an outbreak, and in the short and long term. However, there remain questions about what consequences the impact on HCPs’ mental health will have on levels broader than the individual. Firstly, it seems likely that the mental health issues evidenced here would impact patient care. However, what is not clear from the evidence available so far is whether there is something unique about an epidemic/pandemic that would compromise professional functioning, including patient care, or whether this is due to a more general impact of mental health problems in professionals (that also occurs outside the context of an epidemic/pandemic). Secondly, there may be costs at the organizational and societal levels, as HCPs suffering from the psychological impact of the epidemic/pandemic struggle to maintain their previous working hours, thus affecting staffing levels within the health system [ 32 ] and patient care [ 29 ]. What none of the reviewed studies sufficiently addresses is the issue that part of the challenge for HCPs is the increased professional demand at a time when both family stress and personal threat (to health) are also elevated.

This rapid review makes recommendations to reduce the negative impact on HCPs’ mental health from the evidence of risk and protective factors. However, there remains a lack of evidence-based interventions/preventions that can be recommended for implementation with confidence. Evaluation of these recommendations as part of their implementation would assist future preparations for disease outbreaks to reduce and prevent the impact on the mental health of HCPs.

When considering the findings and recommendations of this rapid review, several elements should be noted. The majority of the evidence from accepted primary studies is heavily reliant on cross-sectional studies assessing self-reported symptoms. No accepted study used a longitudinal design with diagnostics. While it is appreciated that this type of data is collected rapidly in a reactive fashion, researchers should consider the importance of gathering high-quality evidence of true prevalence and risk factors. There were not enough studies or details within these studies to distinguish between specific professional groups or health contexts. Consequently, we took a broad-brush approach across professions and contexts when reporting our findings. Furthermore, not all studies had a control group of a non-exposed group but only reported prevalence’s during an epidemic/pandemic. We could also consider if the risk and protective factors for HCPs identified here may apply to other key worker professions currently at risk of contact with infected members of the public e.g., teachers.

Moreover, most of the studies were conducted in Asian countries, with only two coming from Europe, eight from Canada/USA, and four from Africa. It is likely that cultural differences between these countries are associated with different nuances in the expression of psychological outcomes. Currently, studies/reviews are being published on a daily basis related to COVID-19 and by the time of publication, there will likely be a small body of papers that we were not able to include. Finally, we would like to acknowledge that solid evidence and practice guidelines about psychosocial interventions following other large-scale disasters exist, although they do not specifically target HCPs, e.g.,B Juen, R Warger, S Nindl, H Siller, MJ Lindenthal, E Huttner and S Thormar [ 56 ]. However, it is still unknown to what extent these would also be effective in response to an epidemic/pandemic and future research should investigate whether the mental health impact of (and therefore the intervention required following) an epidemic/pandemic is unique or comparable to that of other large-scale disasters.

A rapid review has some limitations [ 7 ], as discussed above. The number of databases searched, languages included, and dates searched were limited. No qualitative studies or grey literature (unpublished or non-commercial material e.g., policy statements or government reports) was included, which may have created a potential (publication) bias. Strengths of the study included strict inclusion/exclusion criteria and only accepted peer-reviewed studies that used validated measures of mental health. Further strengths of this review are that the search terms and strategies were developed in collaboration with specialist librarians and that hand searches of references from accepted full texts were conducted. Additionally, was that multiple researchers cross-checked data extraction to reinforce rigor of the extraction procedures.

Healthcare professionals exposed to working with patients during an epidemic/pandemic are at heightened risk of mental health problems in the short and longer term. These mental health problems may interfere with the quality of patient care, although further evidence is needed. Healthcare staff need to be provided with psychosocial support to protect their mental wellbeing if they are to continue to provide high quality patient care. Few evidence-based prevention or early intervention programs exist so far. Several recommendations based on risk and protective factors of this review, as well as on additional primary studies are proposed.

Availability of data and materials

The selection of papers and data used to conduct this rapid review will be made available by the authors on request.


  • Healthcare professionals

Posttraumatic stress disorder

Coronavirus disease 2019

Severe acute respiratory syndrome

Middle East respiratory syndrome

Influenza pandemic

Avian influenza

Cognitive behavioral therapy

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We would like to thank Yves Frote for stimulating and discussing this review project with us.

No funding was provided for this work but CD and VS are currently supported by the Swiss National Science Foundation (grant number 32003B_172982/1; PI: Antje Horsch). AH is a management committee member of COST action CA18211.

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Stuijfzand, S., Deforges, C., Sandoz, V. et al. Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review. BMC Public Health 20 , 1230 (2020). https://doi.org/10.1186/s12889-020-09322-z

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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


  • 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.


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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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.





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}.


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.


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




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.



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.


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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  • 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


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).


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.


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.

Availability of data and materials

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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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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  • 1 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 2 Division of Infectious Diseases, AichiCancer Center Hospital, Chikusa-ku Nagoya, Japan. Electronic address: [email protected].
  • 3 Department of Family Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 4 Department of Pulmonology and Respiratory Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 5 School of Medicine, The University of Western Australia, Perth, Australia. Electronic address: [email protected].
  • 6 Siem Reap Provincial Health Department, Ministry of Health, Siem Reap, Cambodia. Electronic address: [email protected].
  • 7 Department of Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Warmadewa University, Denpasar, Indonesia; Department of Medical Microbiology and Immunology, University of California, Davis, CA, USA. Electronic address: [email protected].
  • 8 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Clinical Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 9 Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, MI 48109, USA. Electronic address: [email protected].
  • 10 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • PMID: 32340833
  • PMCID: PMC7142680
  • DOI: 10.1016/j.jiph.2020.03.019

In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan City, Hubei Province, China. On January 30, 2020 the World Health Organization declared the outbreak as a Public Health Emergency of International Concern. As of February 14, 2020, 49,053 laboratory-confirmed and 1,381 deaths have been reported globally. Perceived risk of acquiring disease has led many governments to institute a variety of control measures. We conducted a literature review of publicly available information to summarize knowledge about the pathogen and the current epidemic. In this literature review, the causative agent, pathogenesis and immune responses, epidemiology, diagnosis, treatment and management of the disease, control and preventions strategies are all reviewed.

Keywords: 2019-nCoV; COVID-19; Novel coronavirus; Outbreak; SARS-CoV-2.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

  • Betacoronavirus
  • Clinical Trials as Topic
  • Coronavirus Infections* / epidemiology
  • Coronavirus Infections* / immunology
  • Coronavirus Infections* / therapy
  • Coronavirus Infections* / virology
  • Disease Outbreaks* / prevention & control
  • Pneumonia, Viral* / epidemiology
  • Pneumonia, Viral* / immunology
  • Pneumonia, Viral* / therapy
  • Pneumonia, Viral* / virology

308 COVID-19 & Pandemic Essay Topics for Students

Although in May 2023, COVID-19 was declared to no longer be a public health emergency, it is still a global threat. Many issues remain understudied on the topic of COVID-19, and we suggest a list of pandemic essay topics where you can address the challenges and profound impacts of global health crises. In this collection of COVID-19 essay examples for students, we touch upon the multifaceted dimensions of pandemics, from their origins and management to their social, economic, and psychological implications. Look through these essay titles and examples and write a perfect paper!

🦠 TOP 10 COVID-19 Essay Topics for Students

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  • The Global Response to COVID-19.
  • The Impact of Past Pandemics.
  • Mental Health in the Pandemic.
  • Pandemics and Social Inequities.
  • Economic Resilience in Times of Crisis.
  • The Role of Technology in Pandemic Response.
  • Science vs. Misinformation.
  • How Pandemics Impact Supply Chains.
  • Healthcare Systems Under Strain.
  • After the Pandemic: Urban Planning and Public Spaces.

  • 2009 H1N1 Flu Pandemic, Vaccination and Rates Extensive studies of the virus confirmed that it possessed certain characteristics that had not been detected in similar viruses before.
  • Negative Impact of the 2020 COVID Pandemic on World Industries It is crucial to evaluate how different authorities and global companies have overcome the 2020 COVID pandemic's negative impacts.
  • AIDS Pandemic: Impact on Human Health Scientific evidence has shown that AIDS is the causative virus of the Human Immunodeficiency Virus (HIV) that is the cause of death because it affects the immune system.
  • The Coronavirus Pandemic: Detergents Against the Germs The purpose of the work is to study the effectiveness of hand sanitizers, soap, and simple running water as methods to fight bacteria and stop the spread of many viruses.
  • “Senate HELP Hearing on Coronavirus Responses and Future Pandemic Preparedness”: An Overview “Senate HELP Hearing on Coronavirus Responses and Future Pandemic Preparedness” is a policy meeting aimed to control the damage that a lack of prompt response caused.
  • Global Pandemic Issues: Prevention of Infection and Transmission of COVID-19 For the last seven months, the world has been dealing with the coronavirus disease 2019 pandemic. The disease is caused by severe acute respiratory syndrome coronavirus 2.
  • Ethical Controversies During COVID-19 Pandemic Regulations The paper discusses the ethical controversies involving USAA and Shake Shack from moral and economic points of view.
  • Psychological Effects of Pandemic Control Measures Isolated working conditions combined with the lack of social contacts cause people to experience an increased feeling of stress and anxiety.
  • Intimate Partner Violence in the Australian Media During the COVID-19 Pandemic The pandemic and people’s resulting uncertainty about jobs and health can have a range of negative psychological effects, thus making conflicts between partners more common.
  • The Effect of Global Pandemic on the Role of Sports in Our Lives The pandemic has changed the way I view sports and their meaning in people’s lives, and I no longer view sports as primal for people.
  • Impact of the Coronavirus Pandemic on Human Relations In the article, the author analyzes how the coronavirus pandemic has impacted his relationships with family and friends.
  • City Planning and Pandemic: Efficient Approach The impact of pandemics can be significantly reduced through problem-solving urban design and regional planning.
  • Budgetary Change: Unstable Situation Due to the Pandemic The purpose of this paper is to explain the issue of cutting funding for education and identify the most affected sides.
  • Impact of COVID-19 Pandemics on the Environment The spread of the COVID-19 and the contingency prevention measures harm the environment, and it is urgent to solve problems like the growing volume of waste.
  • Pandemic and Its Aftermath Impact The pandemic will be followed by an increase in mortality rates among the vulnerable population such as the poor, the elderly, the chronically ill.
  • Australian Freight Companies’ Ethics During the COVID-19 Pandemics This essay aims to examine the actions of freight companies from Australia in the current situation and assess whether they are appropriate in view of morality and ethics.
  • Racist Assaults Against Asians and Coronavirus Pandemic The coronavirus pandemic has given rise to the horrifying outbreak of xenophobia and racist attacks on Asians worldwide, and the United States is, unfortunately, no exception.
  • Hoarding and Opportunistic Behavior during COVID-19 Pandemics Covid-19 epidemic has been characterized by unscrupulous practices such as hoarding and profiteering, which are considered deceptive and dishonest.
  • Streaming Service and Elderly During COVID-19 Pandemic The purpose of this paper is to explore the effect of streaming on the elderly in the course of the Covid-19 lockdown.
  • Pandemics and Epidemics that Changed the World This discussion focuses on the period between 1492 and 2020 to understand how some of the unexpected pandemics and epidemics in the West triggered unprecedented changes.
  • Employees Retention During COVID-19 Pandemic The pandemic has caused people around the world to get used to working remotely. The crisis situation became an incentive for the transition to more technological processes.
  • The Company’s Exit from the Crisis in a Pandemic The company’s recovery from a crisis, is possible if the human potential is preserved, highly motivated staff, and optimization of the company’s organizational structure.
  • Covid-19 Pandemic Effect on the Economy The COVID-19 pandemic had a profoundly detrimental consequence on the state of micro- and macroeconomic activity.
  • Mitigating the Impact of the Novel Coronavirus Pandemic The United Kingdom, India, Brazil, South Africa, and Germany. Emphasizing that in the year 2020, the world has faced one of its worst economic crises in modern history.
  • Pandemic Effects on Churches and Families Both churches and families appreciate those moments when they can be together, as it is often taken for granted pre-Covid 19.
  • The Covid-19 Pandemic Analysis Coronavirus, or Covid-19, is a contagious virus that began in December 2019. It causes an infection on the upper throat, sinuses, and nose.
  • Online Learning During the Pandemic When it comes to the notion of education, the process of online learning has become salvation to the problem of education access and efficiency.
  • Airline Labor Relations During the COVID-19 Pandemic This essay explores the impacts of the COVID-19 pandemic on airline labor relations, with labor unions’ functions and factors that increase the need for an effective workforce.
  • Ethical Perspective on Pandemics The ethics of health care under the circumstances of infection epidemics are to be questioned due to the high risks to doctors’ and nurses’ health and life safety.
  • The Sports Industry During the Covid-19 Pandemic This article provides a literature review on the financial pressures and constraints faced by the sports industry as a result of the Covid-19 pandemic.
  • Project Management in Healthcare During the COVID-19 Pandemic The spread of coronavirus infection was the factor, which defined the informatics research orientation of the global medical community in 2019 and 2020.
  • The Impact of the Worldwide COVID-19 Pandemic on Essential Social Values In 2020, social life was globally affected by the spread of COVID-19, leading countries to establish lockdowns and promote social distancing.
  • How the Pandemic Has Worsened Opioid Addition The article “ There Was Nothing to Help Me’: How the Pandemic Has Worsened Opioid Addiction” by Sainato discusses the problems with opioid addiction during the COVID-19 pandemic.
  • Pandemics in History Black Death, smallpox, Spanish flu were one of the most lethal and impactful pandemics. This paper describes the origin of these three outbreaks and analyses social consequences.
  • Social Barriers During the COVID-19 Pandemic This paper will focus on the discussion of the socio-economic barriers and changes to improve the structure of health care.
  • Psychonomics of Consumers During the covid19 Pandemic During the COVID-19 pandemic, the consumer’s behavior regarding the seeking of protective equipment and testing has shown two distinct choices of people.
  • COVID-19 Pandemic and a Globalized Economy Before the pandemic, the global economy was on its path towards making the world an economic machine that has practically no borders and barriers to hinder the exchange of goods.
  • COVID-19 Pandemic: What We Can Learn From the Past? The paper states that the 1918 influenza or the Spanish flu spread can be a source of knowledge to deal with the recent COVID-19 pandemic event.
  • Nature Relatedness and Well-Being during COVID-19 Pandemic Today, society passes through hard times because of the COVID pandemic that affects all spheres of human activity and preconditions the emergence of multiple changes in lifestyles.
  • Managerial Accounting in the COVID-19 Pandemic Any company or an organization with a dream of succeeding in the world of business should consider managerial accounting as a critical element of propelling its objectives.
  • COVID-19 Pandemic’s Impact on the Environment There is a common opinion that the COVID-19 pandemic has a positive impact on the environment. But is ambiguous, and there are certain negative consequences.
  • City Planning and Pandemics: Efficient Approach During pandemics people have to reduce their travel distances, so it is important to consider the presence of healthcare clinics in each individual neighborhood.
  • The COVID-19 Pandemic Impact on Social Values The author proposes a research topic on that humanity should create new social values in the context of a pandemic, and not try to preserve obsolete ones in unusual life.
  • The Impact of COVID-19 Pandemic The year 2019 will forever be engraved in many people’s hearts as the time when a virus known as the COVID-19 invaded almost all the sectors, thereby disrupting daily activities.
  • Florida Administration’s Response to the Coronavirus Pandemic This essay is devoted to a critical analysis of the actions of the authorities to prevent the spread of coronavirus infection and their impact on the author of the work.
  • Reflection on the COVID-19 Pandemic The COVID-19 pandemic has affected the human race in all spheres of life by altering the strength which holds every system.
  • Leadership and Management During COVID-19 Pandemic The current leadership framework that lifts a substantial amount of responsibility from the staff might help them feel relieved, yet will reduce the efficacy of their performance.
  • COVID-19 Pandemic: Economic Factors and Consequences Fears related to the spread of the COVID-19 virus and its impact on the global economy negatively affected investor sentiment, leading to a sharp decline in share prices.
  • Christianity and the COVID-19 Pandemic According to several news sources, the coronavirus outbreak revealed some of the flaws of Christianity, in this paper, this news item is going to be analyzed in detail.
  • Job Satisfaction Levels During the COVID-19 Pandemic The COVID-19 pandemic has transformed many established practices and arrangements in people’s social lives, medicine, and business.
  • Is the Pandemic Beneficial?: Argument with an Opossum Pandemic has immeasurably affected all spheres of human activity. At the same time, the pandemic has both advantages and disadvantages
  • Consumer Behavior During the COVID-19 Pandemic The pandemic has affected consumers’ purchasing behaviour. People have been spending less money on items such as clothes, jewelry, shoes, electronic gadgets, and games.
  • Mental Health Buring a COVID-19 Pandemic Prevention practices that include assessment for mental health problems, psychosocial support should focus on the individuals who are at high risk of psychological problems.
  • Public Health: The Issue of HIV/AIDS Pandemic The public is involved in the prevention of HIV through the enhancement of public awareness. Advertisements that show prevention measures should be made for the public.
  • The Impact of COVID-19 Pandemic on the Community of Charleston, South Carolina The impact of COVID-19 is considerable to such a degree that people experience limitations in the field of vital needs, such as food and accommodation.
  • Changing Health Behavior in Current Pandemic Situation As the attention to their implementation is of utmost importance in the present situation, the most effective ways of raising public awareness must be found.
  • Effects of the Pandemic on Early Childhood Education and Children The pandemic has placed early childhood education at serious risk. The closing of learning institutions that provide young children with education is a threat to their potential growth.
  • Influenza Pandemic Outbreak Overview The present paper has discussed how the systems approach can be utilized by the Director of CDC to establish an immediate response to influenza outbreak.
  • Transactional Model of Stress and Coping and the Effect of the Pandemic on Nurses’ Well-being Naturally, health care is one of the sectors, which was affected the most by the pandemic. Nurses play a pivotal role in this system, being the cornerstone of health care service delivery.
  • School Closure During Influenza Pandemic This paper describes the school closure intervention in the Australian context in response to the outbreak of influenza (H1N1) pandemic in 2009.
  • Picnics Become Popular Around the Globe During Pandemics This paper explores picnicking and how it varies across different countries. This trend is exacerbated by the chilling weather, which seems to favor dining outdoor picnicking.
  • Streaming Service for the Elderly During the COVID-19 Pandemic The purpose of this paper is to explore the effect of streaming on the elderly in the course of the strict Covid-19 lockdown.
  • Influenza Pandemic Outbreak Analysis The group case study involves analysis of preparedness plan and challenges of an influenza pandemic on a developing nation.
  • Labor Market Developments During the Covid-19 Pandemic In the first quarter of 2020, the U.S. economy experienced its worst contraction in a decade as restrictions were imposed in the country to slow the spread of coronavirus.
  • Pandemics & Biothreats and Governmental Responses Government agencies across the world have developed comprehensive measures and policies aimed at dealing with biothreats and pandemic outbreaks.
  • Healthcare Rationing During a Pandemic With limited resources to allocate, healthcare providers often have to make decisions about patients’ life and death, especially with the covid pandemic.
  • Racial Inequalities in the Context of Pandemic Vaccination To concretize the study, a current journalistic article in The New York Times was chosen to highlight racial inequalities in the context of pandemic vaccination.
  • Key Takeaways from the Coronavirus Pandemic A vital takeaway from the coronavirus outbreak is that pandemics do not have a schedule, and the next one could occur in the next five, ten, or fifteen years.
  • Covid-19 Pandemic and Mental Health of American Population After the Covid-19 outbreak, the depression rates in the US have increased threefold. The pandemic cost many people their employment, cut off social ties, and separated families.
  • COVID-19 Pandemic: Businesses Negotiation Strategies The use of negotiation strategies can help businesses to reduce losses and service interruptions during the COVID-19 pandemic, thus offering a significant competitive advantage.
  • Children and the COVID-19 Pandemic The paper provides information about those influences of the coronavirus pandemic and school districts’ closures that most people are unaware of.
  • How Can Irish Funeral Traditions Help the Bereaved People Cope with Losses during the Pandemic? Losing close people is always a psychologically painful experience. Bereavement and funerals allow people to find solace in the fact of death.
  • Existence of God in Times of Covid-19 Pandemic This paper examines whether God exists or not and goes further to describe His true nature using the ongoing coronavirus disease of the COVID-19 pandemic.
  • Durkheim: Pandemic and Functionalism Durkheim defined the concept of division of labor as follows: “a way of investigating the moral consequences of the growing complexity within modern societies”.
  • Public Policy Meeting: “VA Telehealth During the COVID-19 Pandemic” The meeting “VA Telehealth During the COVID-19 Pandemic: Expansion and Impact” was aimed to examine key agendas on how the VA utilized telehealth to fill the cancellation gap.
  • Physical Activity Impact on Psychological Health During COVID-19 Pandemic This research aims to determine the impact of physical activity on psychological health during the COVID-19 Pandemic.
  • Zoom Video Communications During Covid-19 Pandemics The case study shows that Zoom company has become one of the most preferred brands in this industry since the COVID-19 pandemic because of its unique products.
  • Mental Health During the Pandemic: Research Design, Steps, and Approach The health and well-being of people worldwide have been impacted by the COVID-19 pandemic and measures imposed to prevent its spread.
  • Food and Beverage Plan: The COVID-19 Pandemic Influence The COVID-19 pandemic has affected many social spheres. The food and beverage industry is still in the conditions of many restraints and limitations.
  • VA Telehealth During the COVID-19 Pandemic: Expansion and Impact This paper discusses the public hearing – a session held by the House Committee on Veteran’s Affairs during which the state of things regarding telehealth provision at VA.
  • COVID-19 Pandemic: Preparing a Presentation The social science issue I work on is urgent for the audience as it is related to the recent COVID-19 pandemic and shares actual data about changes among social institutions.
  • Autoethnography: The COVID-19 Pandemic The paper discusses COVID-19 pandemic had a considerable impact on all the spheres of life, and the influence was aggravated by the abruptness of the outbreak.
  • The Covid-19 Pandemic of 2019-2021 The work exhibits the major aspects concerning COVID-19: its history and discovery, structure, symptoms and the effects on mental health, social impact, and prevention.
  • Global Society: Before and After The Coronavirus Pandemic This paper compares social gatherings, networking, safety, communicational processes, perception of mental health, and balance in pre-pandemic society and today’s post-pandemic one.
  • Singapore Airlines’ Strategic Plan During the COVID-19 Pandemic Due to the volatility brought by the pandemic, it is highly important for Singapore Airlines to engage in a promotional marketing strategy to offer customers the best deals.
  • The COVID-19 Pandemic Organizational Risk Management Strategies In terms of COVID-related risk mitigation strategies, organizations refer to the calculation of Time-to-Recover to ensure smooth and resilient existence from the crisis.
  • Social Solidarity During the Pandemic The paper examines the concept of social solidarity and evaluates it as a mechanism promoting public health when people depend on one another.
  • Comparison of How Communities React to Plagues and COVID-19 Pandemic The City of Oran next to the Mediterranean Sea in Algeria is a setting of the famous fiction outbreak of the bubonic plague.
  • Social Changes After the Coronavirus Pandemic The global coronavirus pandemic is rapidly changing the economic, behavioural, and social aspects of people’s lives.
  • The COVID-19 Pandemic in US and World History In conjunction with WHO, various organizations looked for safer ways the vaccine could reach billions of people. The pandemic taught people a viable lesson.
  • Poor Management & Care Quality During the COVID-19 Pandemic The COVID-19 pandemic revealed many inadequacies of healthcare management worldwide, for example, increased working among nurses was reported to affect their performance.
  • Can Coronavirus Pandemic Lead to World War III? The coronavirus pandemic affects the lifestyle of the entire humanity. There is an opinion that the crisis caused by the lockdown may lead to World War III.
  • The COVID-19 Pandemic: Economic Impacts This paper aims to find the economic impacts of the coronavirus by exploring current financial status in the United States and around the world.
  • The Effect of the COVID-19 Pandemic on Businesses The paper argues the pandemic, despite all of its negative effects, actually helped some businesses to succeed and grow.
  • COVID-19 Pandemic’s Impact on Hospitals The novel coronavirus has impacted hospitals and healthcare facilities, leading to increased strain on limited available resources and increased outpatient visitations.
  • US Actions Concerning COVID-19 Pandemic The paper aims at examining the US actions concerning the COVID‑19 pandemic in the aspects of fiscal policy and biblical government principles.
  • Restaurant Business During The Pandemic The critical condition for the effectiveness of the restaurant business is the requirement to follow social responsibility.
  • Preparing a Child for School During COVID Pandemic To most adequately prepare a child for school life in the era of raging strains of coronavirus, a parent needs to be aware of their position in current social processes.
  • Healthcare for Underserved Communities During Covid-19 Pandemic This paper will present details of three articles that focus on disclosing barriers to care that emerged during the pandemic for underserved communities.
  • Tourism and Sustainable Development During the COVID-19 Pandemic It is expected that tourism-related businesses will be fighting insolvency in the next few years because of the adverse effect COVID-19 has had on the sector.
  • Economic Predictions on Recovery After COVID-19 Pandemic Shock This paper analyzes the article “World trade primed for strong but uneven recovery after COVID-19 pandemic shock” to explore economic predictions.
  • Poor Staff Management During the Pandemic Hospital administrators should provide psychological support to their staff to reduce burnout rate, increase productivity, and improve patient outcomes.
  • Relation Between the COVID-19 Pandemic and Depression The paper is to share an insight into the detrimental effects of the COVID-19 pandemic on the mental health of thousands of people and provide advice on how to reduce its impact.
  • Psychological Effects COVID-19 Pandemic Leading to Hospital Nursing Shortage The paper incorporates the Grounded Theory as the theoretical basis for conducting guided nursing research. It is a model used in the nursing sphere.
  • White and Black People in USA During COVID-19 Pandemic The article discusses United States of America which are considered to be a multinational country with substantial racial diversity.
  • The Covid-19 Pandemic’s Influence on Socialization The recent COVID-19 pandemic has represented the topic of secondary socialization, unearthed the true extent of financial and social inequality across the world.
  • Arguments Against Masks During Pandemic and Personal Freedom The arguments of mask refusers are invalid. However, their actions lead to a violation of the top human right – the right to life.
  • Domestic Violence During COVID-19 Pandemic The paper reviews the articles: “Home is not always a haven: The domestic violence crisis amid the COVID-19 pandemic”, “Interpersonal violence during COVID-19 quarantine.”
  • Parents and Children’s E-Safety Education During the Pandemic When it comes to children’s education from a Constructivist perspective, parents are to engage with the children’s activities online to make sense of the Internet knowledge.
  • The Story of Sam, OCD, and the COVID Pandemic Her name is Sam, short for Samantha; you may not tell by looking at her, but she has a mental condition called obsessive-compulsive disorder.
  • Hand Sanitizers in COVID-19 Pandemic: Pros and Cons The paper states that hand sanitizers are indeed associated with controversial aspects and have both positive and negative properties.
  • The Sphere of Leadership: Impact of the COVID-19 Pandemic This research paper is aimed at evaluating the influence of the COVID-19 pandemic on the sphere of leadership.
  • Hate Crimes Against Asian Americans During the Pandemic An outbreak of hate crimes targeting Asian Americans after the outbreak of the pandemic has led to thousands of violent episodes against members of the group.
  • Built Environment and Pandemics Healthy built environments have services and resources that contribute to the physical, mental, and social wellbeing of the people who occupy it.
  • Healthcare Policy Influences: COVID-19 Pandemic The research indicates that the impactful aspect of the economy of a nation became the most prominent during the COVID-19 pandemic.
  • Social Effects of the COVID-19 Pandemic Social conflicts play a significant role in the structure of society and have a decisive effect on all spheres of life of an individual and society as a whole.
  • How the Corona Virus-19 Pandemic Affected Society This paper discusses the Corona Virus-19 effect on society’s stratification and social classes, politics, families and marriages, and problems in education that students faced.
  • Observing Harmony in Our Life During Covid-19 Pandemic During the pandemic, there have been many reasons to reflect upon the essence of the never-ending sequence of challenges that form the sequence of our lives.
  • Consumer Behavior: Impact of the COVID-19 Pandemic Consumers come out of COVID-19 with very different habits, and the main challenge for businesses, both small and large, is to find an approach in the new environment.
  • Pre-pandemic and Pandemic Consumer Behavior The pandemic of COVID-19 has had a noticeable influence on consumer behavior around the globe that will most probably be long-term.
  • The COVID-19 Pandemic Has Brought Us Too Close Together The resources presented in the articles depict a new reality where violence and riots occur due to a depressed populace who can’t stand any injustice.
  • Leadership Approaches During the COVID-19 Pandemic As the COVID-19 pandemic continues, leaders need to act in an environment of unpredictability and incomplete information.
  • Texas Judiciary During the COVID-19 Pandemic The current paper indicates that the main issues faced by the Texas justice system and state judges are caused by the COVID-19 pandemic.
  • Impact of the Coronavirus Pandemic on the Global Economy The paper is aimed to overview the Coronavirus pandemic’s characteristics and analyze the outcomes of the disease outbreak within major economic spheres.
  • Covid-19 Pandemic-Related Macroeconomic Issues COVID-19 fueled many macroeconomic issues. The first is high inflation which increased the living costs and pressure on low-income earners.
  • Long-Term Changes in Information Technology During the Pandemic of COVID-19 The outbreak of the COVID-19 in China is not only destructing the global economy but it can also have a positive effect on the development of the IT industry.
  • The COVID-19 Pandemic’s Impact on Australia This work will focus on discussing some of the considerations necessary for the Australian business to start its operation in a new market environment during COVID-19.
  • Supply Chain Management Challenges Amid the COVID-19 Pandemic The increasing number of suppliers and business continuity risks must be considered to find relevant solutions to the Kuwaiti supply chain management problem.
  • Global Pandemic of COVID-19 From an Epidemiological Perspective The epidemiological perspective of the COVID-19 pandemic requires studying the statistical data for identifying patterns that could be addressed or eliminated.
  • Cancel Culture Before and After the COVID-19 Pandemic The case study will analyze various academic studies with a social science focus and will assist in defining how the cancel culture has been shaped by the pandemic.
  • Mental Health and COVID-19 Pandemic The Covid-19 pandemic is one of the biggest global challenges in the last 50 years. The virus has affected world economies, health, societal cohesion, and daily life.
  • Impact of the COVID-19 Pandemic on Human Well-Being The COVID-19 pandemic taught people to appreciate their social ties and health more and helped them reconsider the impact of social isolation on human well-being.
  • The Dabbawalas and the COVID-19 Pandemic The global COVID-19 pandemic cannot go unnoticed for the dabbawalas, which is a system of lunchbox delivery and return services for India’s employees.
  • Virtual Teams’ Adaptation to the Conditions of the COVID-19 Pandemic Virtual teams’ adaptation to the conditions of the COVID-19 pandemic happened through forced utilization of technology to establish effective communication.
  • Older Adults Surviving the COVID-19 Pandemic: The Mental Health Benefits of Physical Activity The aim of this paper is to identify the effect of physical activity on mental health among older adults during the COVID-19 pandemic.
  • Extraversion & Social Connectedness for Life Satisfaction During the Pandemic This laboratory report critically examines the effects of strict isolation and social distancing on perceptions of self-satisfaction.
  • The COVID-19 Pandemic Impact on Society COVID-19 has disrupted daily life and slowed the global economy. In addition, thousands of people have been affected by this pandemic, and are either sick or dying.
  • Review of “For Millions, the Pandemic Is Far From Over” Article The article by Doheny, presented by the reputable healthcare source Medscape, examines the challenges of immunocompromised Americans.
  • Telehealth in the Pandemic: Benefits & Limitations Despite the benefits of telehealth during the pandemic period, the older population still has reservations about the suitability and efficacy of such technologies in the long run.
  • COVID-19 Pandemic and Valuable Cargo The COVID-19 pandemic has played a significant role in changing logistics, with the supply chain playing a more critical role than ever before.
  • COVID-19 and Playing Sports During a Pandemic The review focuses on three significant sports areas under the conditions of a pandemic: health, commercialism, and structural aspects.
  • The COVID-19 Pandemic and Its Effects Worldwide Covid-19 has remained a threat in many countries in the last two years. Numerous restrictions and precautions have been implemented in various nations.
  • Impact of COVID-19 Pandemic on the African American Communities This paper analyzes how the COVID-19 pandemic affected the economic aspect of the African American communities. A female and two males were interviewed.
  • The Influence of the COVID-19 Pandemic on the Housing Market in Singapore Despite the COVID-19 pandemic, which has caused various economies around the globe to fumble and struggle, the housing market in Singapore tends to remain healthy.
  • Recovery the Post Pandemic World The paper briefly explains what sort of recovery the post-pandemic world will likely experience and how Ireland is positioned to cope or change tact.
  • The COVID-19 Pandemic and Labor Market Dynamics The labor market dynamics of the COVID-19 recession in the United States are studied using a search-and-matching model incorporating temporary unemployment.
  • Tourism Sustainability After COVID-19 Pandemic This essay will discuss how the COVID-19 pandemic has influenced the sustainability sector of the tourism industry.
  • Impact of the COVID-19 Pandemic on Air Canada The current project is going to discuss the impact of the COVID-19 pandemic on Air Canada and provide a PESTEL analysis of the organization.
  • The H3N2 Virus Pandemics of 1968 The H3N2 virus contained two genes derived from the six genes from the A(H2N2) virus, associated with the 1957 H2N2 pandemic.
  • COVID-19 Pandemic in Media: Agenda Setting Theory For the analysis, the currently gaining attention theory about the laboratory origin of the virus was chosen, as well as its coverage in authoritative publications.
  • The US Stock Market Affected by the COVID-19 Pandemic Despite the terrible effects that the coronavirus has had on the stock market in the United States, it is clear that the country has gained a great deal from the adverse effects.
  • Pandemic’s Impact on Mental Health & Substance and Alcohol Abuse While substance use disorder can impose mental health challenges on those who consume drugs, COVID-19 affects the psychology of all humankind.
  • United States Economy’s Outlook After Pandemic The United States has shown signs of a rebound after the Covid-19 pandemic through the rising GDP and the low unemployment rates witnessed in the country.
  • Pandemic-Related Changes in Consumer Behavior The COVID-19 pandemic has affected consumer behavior around the globe so considerably that new trends have emerged that are mostly based on seeking stability.
  • The COVID-19 Pandemic’s Impact on the Airline Industry The main objective of the paper was to provide evidence-based coverage of the impact of the Covid-19 pandemic on airline operations around the world.
  • Post-Pandemic Work Environment The COVID-19 pandemic has changed the way people approach work because the majority of companies had to transition to remote work.
  • American Pandemics From Columbus to Coronavirus The decisions made by previous generations of Americans during epidemics led to the development of structural racism and class segregation.
  • Racial Discrimination in the Industry of Face Masks During the COVID-19 Pandemic This research, done in an industry that produces face masks, provides a clear image of racism during the coronavirus pandemic period.
  • Digital Technologies During the COVID-19 Pandemic The pandemic promoted the development of advanced technologies and their implementation of them worldwide in healthcare, businesses, education, and people’s everyday lives.
  • Police Killing Black People in a Pandemic Police violence as a network of brutal measures is sponsored by the government that gives the police officers permission to treat black people with disdain.
  • Pandemic in Seurat’s “A Sunday Afternoon on the Island of la Grande Jatte”
  • Planning in a Post-Pandemic World
  • Virtual Visit to Louvre During Covid-19 Pandemic
  • “And the Band Played On” During the AIDS Pandemic
  • Production and Growth During the Pandemic: A Case of U.S. Manufacturing
  • The Impact of the COVID-19 Pandemic on the International Trading
  • Social Institutions: Impact of the COVID-19 Pandemic
  • Pandemic Challenge and Economic Inequality
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Food service industry in the era of COVID-19: trends and research implications

1 School of Hospitality Management, The Pennsylvania State University, State College, PA 16802, USA.

2 Department of Food and Nutrition, Yonsei University, Seoul 03722, Korea.

Coronavirus disease 2019 (COVID-19) is a new type of respiratory disease that has been announced as a pandemic. The COVID-19 outbreak has changed the way we live. It has also changed the food service industry. This study aimed to identify trends in the food and food service industry after the COVID-19 outbreak and suggest research themes induced by industry trends. This study investigated the industry and academic information on the food and food service industry and societal trends resulting from the COVID-19 outbreak. The most noticeable changes in the food industry include the explosive increase in home meal replacement, meal-kit consumption, online orders, take-out, and drive-through. The adoption of technologies, including robots and artificial intelligence, has also been noted. Such industry trends are discussed in this paper from a research perspective, including consumer, employee, and organizational strategy perspectives. This study reviews the changes in the food service industry after COVID-19 and the implications that these changes have rendered to academia. The paper concludes with future expectations that would come in the era of COVID-19.


Coronavirus disease 2019 (COVID-19) captured public attention as a new type of respiratory disease. The World Health Organization (WHO) announced it as a pandemic on March 11, 2020 [ 1 ]. Although most people heard “corona virus” for the first time, humans have experienced seven types of coronaviruses, including severe acute respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2015. COVID-19, like SARS and MERS, is a respiratory disease with similar symptoms. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19, is genetically 80% similar to SARS-CoV, the virus that causes SARS [ 2 ]. The viruses for COVID-19, SARS, and MERS are stable and active at 4 °C [ 3 ]; they become inactive as the temperature increases to 65–70°C [ 4 ]. As COVID-19 is transmitted via droplets, aerosols, and direct contact, wearing masks and washing hands with disinfectants are the foremost defensive methods. The COVID-19 virus also come out of human activities like breathing, speaking, coughing, and sneezing [ 5 ]. As a major route of COVID-19 transmission is droplets, human contact should be avoided to prevent infection. Furthermore, eating food together, such as Korean soup and side dishes, should be avoided, because the droplets can transmit the COVID-19 virus [ 6 ]. Therefore, foodservice operations have been one of the primary sources of COVID-19 transmission. During the COVID-19 era, people look for healthy foods and adopt behaviors to prevent virus transmission. The COVID-19 outbreak has resulted in novel trends in the foodservice industry.


Emergence of covid-19 new normal era.

The COVID-19 outbreak brought a situation that people have never experienced. A new word, “a new normal era after COVID-19,” was coined. The era of Before Corona (B.C.) was separated from that of After Corona (A.C.) because people can never get back the days before the pandemic struck. The word “new normal” was used at the time of the global economic crises initiated by the US sub-prime mortgage during 2007–2008 [ 7 ]. A new normal indicates a new norm for the economic standards. The new normal After Corona described the situation as H (healthcare), O (Online), M (manless), and E (economy at home): healthcare as heightened public interest in health and safety; online as a core essence of digital economies with the advantages of artificial intelligence, big data, and 5G; manless as a proven safety and efficiency during the course of prevention from coronavirus transmission; economic activities at home while staying long hours at home [ 7 ]. Such “new normal” also took place in the food service industry.

Non-human contact (untact) purchasing

Most of all, an explosive increase has been observed in the foodservice purchasing using untact methods. Contrary to the dramatic decrease in the sales of restaurants and institutional foodservices, Starbucks Korea experienced a sales increase of 32% from January to February 2020, compared to the same months in 2019 [ 8 ]. In fact, the orders made via Siren contributed to a 25% increase in terms of the purchase number, compared to the previous year [ 9 ]. The outcome explains consumers’ intention to use untact services to minimize human contact, which will be expanded in the future. Since the order could be made online, the drive-through pick-up of the ordered products increased, from café, bakery, and fast foods to all kinds of restaurants, including even Sish-shop [ 10 ]. McDonalds expanded drive-through stores in the US and China, which resulted in a double-digit increase in sales in September 2020, compared to the same month of 2019 [ 11 ].

Explosive increase in home meal replacement (HMR) and meal-kit

One of the segments that has benefitted most from the COVID-19 outbreak is the meal-kit and HMR products [ 12 ]. While people stay at home, they care more about health and have time to cook. In the US, the sales of meal-kit products in 2020 became 2 times higher than in the previous year [ 13 ]. The major players in the meal-kit industry, Blue Apron, HelloFresh, and Home Chef, experienced a 49% increase in the number of customers. The meal-kit products satisfy the needs of a variety of customers, including vegan, gluten-free, children, and patients with diabetes [ 14 ]. In Korea, since the COVID-19 outbreak, the sales of meal-kit brands have rapidly increased, while offline retail brands rushed into the meal-kit segments with the names of Simply Cook (GS Retail), ChefBox (Hyundai Department Store), Yorihada (Lotte Mart), Gourmet 494 (Galleria), and Peacock Meal Kit (E-mart) [ 14 ]. The delivery of online order food and HMR food services increased by 77.5% in 2020, compared to the previous year [ 15 ]. Further, people are more concerned about health and look for healthy foods. Consumers purchased more high-protein salads with low calories, health-protection HMR, and fresh ingredient meal-kit [ 16 ].

Acceleration of food tech

COVID-19 resulted in the acceleration of food technology. Robotics in foodservice operations has been expanded significantly. Manless cafés, such as Briggo in USA, Lounge X in Korea, and Chowbotics in California, are its good examples [ 17 , 18 , 19 ]. Chowbotics is the first manless café to purchase fresh produce. Cooking robots work at various positions, such as making hamburgers in a fast-food chain (Miso Robotics in White Castle Burger in California), working at a pasta kitchen (DaVinci Kitchen, Germany), and serving in chicken restaurants (Robert Chicken, Korea) [ 20 , 21 , 22 ]. Moley is the first robot to cook gourmet cuisines using artificial intelligence techniques [ 23 ]. Robotics has also been applied to serving (Royal Palace, Netherlands) and deliveries (PepsiCo's, USA) [ 24 , 25 ]. TUG, as a delivery robot for patient meals at the Reading HealthPlex in Pennsylvania, reduced labor costs by 80% [ 26 ]. The UVD Robotics Techniques have been utilized to prevent COVID-19 transmission, while Blue Ocean Robotics played a role in disinfection at the Heathrow International Airport, UK [ 27 ].

New government project

In Korea, the Ministry of Agriculture, Food and Rural Affairs (MAFRA) launched a new project called “Korean Eating Culture Improvement” in May 2020 [ 6 ]. The project aimed to change Koreans' eating behavior of sharing cuisines, which can cause diseases that are transmitted via droplets [ 28 ]. Thus, COVID-19 can be transmitted through such food-sharing behavior. To accomplish this change, MAFRA proposed three activities: one-person portion meal setting, sanitary management of spoons and chopsticks, and employees wearing masks. The project spread all over the country. Authorities of respective provinces supported the restaurants that abided by the above-mentioned activities by rendering certification to the restaurants. The project is expected to construct a safe eating culture with a high level of safety among Koreans.


COVID-19 has drastically changed the world, and many believe that some of those changes may last even after the pandemic is over [ 29 , 30 ]. This reality and future expectations certainly apply to the food service industry as well. This study discusses the kinds of research implications that can be drawn from these changes and future expectations. Such changes can be related to the behaviors and perceptions of consumers and employees, as well as the strategic responses of food service businesses. Considering these primary constituencies of the food service industry, this study attempts to provide meaningful research implications related to COVID-19.

Consumer perspectives

Consumer confidence in dining-in.

Consumers of food service businesses have been through and will continue to undergo tremendous changes due to COVID-19. First, due to lockdown or heavy restrictions on in-dining food services during the pandemic, consumers have been unable to enjoy in-dining experiences, either in a complete or at least a partial manner [ 31 , 32 ]. Even in the absence of government restrictions on the in-dining food service, many consumers were and are reluctant to dine out in a confined food service setting, because of the possibility of COVID-19 transmission [ 33 ]. Moreover, although the vaccination rate is significantly increasing, some consumers either refuse inoculation, thus avoiding dining out, or do not feel safe to dine out in a confined place even after getting vaccinated [ 34 , 35 ]. This lingering concern is understandable because of the high level of uncertainty regarding COVID-19 and its vaccines, especially among the general public [ 36 ]. Accordingly, it is important to understand the real consumer confidence in dining in food service establishments as the COVID-19 development continues and how such confidence can be boosted from the perspective of food service management.

Therefore, food service researchers should pay close attention to the status of consumers' confidence in dining at food service establishments. An important aspect of this examination would be a constant or timely update because since everyone is experiencing this type of pandemic for the first time, how people psychologically recover from and respond to this event is unknown. In particular, as vaccination rate accelerates globally, consumer confidence may recover quickly in a non-linear fashion, or it may first recover quickly but later possibly stall at a certain level due to a particular group of consumers who are either too concerned about the possibility of full recovery or skeptical of vaccination programs, which raise legitimate empirical questions for the food service industry.

Next, the food service business should have a better understanding of how they can improve consumer confidence in in-dining food services. There are various ways that can be implemented to boost consumer confidence in this matter, such as cleaning and sanitizing, restructuring the dining table layout to ensure social distancing, requiring employees and customers to wear face masks, installing transparent plastic panels at the counter and/or between tables, and minimizing human interactions (e.g., use of an electronic tablet for menu ordering or even robots to take orders). Restaurant businesses need to understand which practices to prioritize or emphasize because they do not have unlimited resources to implement them all. An efficient allocation of resources is essential for the food service industry to achieve a more desirable level of profitability because they have a tight profit margin. Furthermore, even when all or most of the possible implementations are feasible and can be done, proper prioritization of these implementations can go a long way to enhance consumer confidence in in-dining services more effectively, which can directly or indirectly impact the establishment's or brand's image, and consumer loyalty and revisit intention eventually.

Accordingly, researchers in the food service literature are recommended to explore, first, the practices that restaurant businesses should consider implementing to improve consumer confidence in in-dining services. In addition, it would be interesting to investigate differing degrees of consumers' perceptions of the importance of such practices to assist the food service business to prioritize relevant practices more efficiently and effectively, especially in terms of resource allocation. It would also be critical to study how to disseminate the information of those practices to the target markets (i.e., a marketing strategy). Some potential questions to answer in this matter may include which marketing media should be used, which practices or messages should be emphasized, and how these messages should be delivered (e.g., with more detailed information in an educational format or with more visual representations of actual practices). To accomplish these research goals, researchers should seek responses from consumers as primary data by utilizing a survey method in an observational or experimental manner. Laboratory experiments and follow-up field studies are desirable. In addition to examining the main effects of the aforementioned factors, researchers would be encouraged to test potential moderating factors such as gender, age, perceptions of COVID-19, having children, pre-existing health conditions, tendency to general risks, and so on in relation to some characteristics of consumers, but also food service types (e.g., fast food, full-service, etc.), franchised vs. independent, size of the food service establishment, managerial abilities, location of the business, and so on in relation to the business characteristics. Understanding these contingent boundaries will help untangle the proposed main relationships among the mentioned factors in a more detailed and comprehensive way.

Untact service

Another interesting topic is the contact-free service, which can be represented by the marketing term “untact service” in the recent literature (from 2017 to be precise) [ 37 ]. The untact service for the food service business includes drive-through, curbside pickup, and delivery. All these forms of untact services have become a norm in the food service industry during the current pandemic and they have helped many businesses in the industry survive the global health and economic crisis [ 38 , 39 ]. It would be important to reveal, first, how untact services have been helped the industry, for example, its impact on sales and profits, and second, how such positive impacts have been heterogeneous contingent on various factors from both consumer (e.g., gender and age) and business perspectives (e.g., location and type of food service).

Post-pandemic change

Lastly, food service researchers should pay attention to which mentioned factors would stick around even after the pandemic is over. Many believe that these new norms during the pandemic, such as the popularity of untact services, fewer interactions with service providers (e.g., service by robotics), and some cleaning and sanitization practices will continue even after the pandemic. However, it is clearly an empirical question that needs to be examined and verified with actual data and rigorous analyses. Even when consumers may anticipate that these practices will still be important and influence their decisions even after the pandemic, their perceptions can certainly change once the pandemic is over. Although we strongly believe that some of these practices will still be important even after the pandemic, which practices will be significant remains to be answered empirically. Understanding the matter will help the food service business to develop more appropriate and timely strategies.

Employee perspectives

Employee turnover.

Similar to consumers of the food service business, employees of the food service business have been experiencing tremendous changes and hardships. For example, the current pandemic has revealed a high level of risk embedded in the food service industry regarding job security from an employee's perspective. Due to the lockdowns and rigid restrictions on food service operations due to COVID-19, countless food service employees have been laid off or furloughed or have experienced a reduced number of working hours. In fact, the food service industry has been one of the hardest hits in the economy by the pandemic [ 33 ]. Since the food service industry is known for a high turnover rate of employees, the added hardship on employees in the industry has been devastating for both employees and employers. Some employees are considering switching to a new career in a different industry because of this hardship, which requires the business to decide what it needs to do to retain and recruit talented employees during and after the pandemic. This is a critical issue even for those employees who stay with their company because they have witnessed a high level of risk and uncertainty in the food service business, which is volatile to external forces such as the pandemic. The industry needs to convince its employees that the industry is still viable and has great potential to grow in the future, especially after the crisis.

Employee attitudes

Understanding the factors during the pandemic that significantly influence employees' various perceptions, such as satisfaction, commitment, and loyalty, is critical for food service management. Employee perceptions play an important role in shaping employees' intention to remain with the company at the end [ 40 , 41 ]. Despite the extreme operational hardships faced by food service employers during the pandemic, they still need to ensure that they show their employees that they care for them and are trying their best to provide them with job security during the pandemic. Such practices can go a long way, possibly making significantly positive impacts on employees' satisfaction with and commitment to their organization because employees also understand how challenging those practices can be during the current pandemic. This kind of positive impact may eventually have an aftereffect on organizational culture and its long-term success. Accordingly, it is suggested that researchers may explore how employers' caring and transparency in their communication influence employees' perceptions and behaviors during the pandemic.

Human resources allocation

Another important issue that needs to be considered regarding employees in the food service business during the pandemic is human resource allocation. As discussed earlier, the food service business had to adapt to a new business environment during the pandemic by extensively implementing untact services, such as drive-through, curbside pickup, and delivery. In doing so, many food service businesses had to deviate from their traditional in-dining services. Such a dramatic transition requires reallocation of human resources to different tasks and related new training. It would be interesting to research how this reallocation impacted the food service business and, in particular, employees' various perceptions about their job and productivity. Additionally, an extension of this research to the post-pandemic period should be encouraged because such investigations may reveal possible lasting benefits (e.g., improved human capital with multiple capabilities) and/or drawbacks (e.g., dissatisfied employees with too many or less focused job responsibilities) in a long-term manner.

Organizational strategy perspectives

Corporate social responsibility strategy and more.

In addition to the customer and employee perspectives, there are potential research topics from an organizational strategy perspective that need attention. Food service businesses can implement or might have implemented certain organizational strategies to cope with the pandemic. Accordingly, it is important for researchers to investigate which business strategies (e.g., corporate social responsibility [CSR], franchising, internationalization, and diversification) generate positive benefits during the pandemic. For example, previous studies found that a firm's engagement in CSR activities can enhance employees' commitment to and satisfaction with their organization, improve their productivity, and reduce turnover intention [ 42 , 43 ]. Furthermore, many previous studies have found that CSR positively impacts consumers [ 44 ] and firm performance [ 45 ]. Hence, it can be interesting to see whether the food service business's CSR investment during the pandemic has the same positive impact (e.g., on customers, employees, and/or business performance). Interestingly, some may argue that an investment in CSR activities during the pandemic has an opposite impact (i.e., a negative impact) on employees, customers, and performance because such investments will cause the cash flow of the business to become even tighter in an extremely difficult time, thus making the probability of its survival slimmer.

It would also be interesting to explore whether a company's pre-existing reputation of being socially responsible can generate business benefits during the pandemic. The pre-existing reputation is not about the company's investment in CSR during the pandemic, but rather the reputation that had already been built before the pandemic, which does not put any burden on the company during the pandemic. In such a case, the pre-existing reputation of CSR may be more likely to provide benefits because it does not cost the company anything during the pandemic, and CSR investment has been found to provide insurance-like protection during a crisis [ 46 ]. All these CSR issues can be viewed as part of or equivalent to environmental, social, and governance (ESG) issues, which have gained considerable attention from the corporate world and public. Although the ESG concept was created and has been used more in the investment context, due to its extensive popularity in the contemporary corporate world, the term is now used more interchangeably with a broader concept, such as CSR. Accordingly, the suggested research topics are timely, even in the context of ESG. However, since all these suggested research issues are empirical questions, they require empirical verification.

Furthermore, similar research studies apply to other business strategies, such as franchising, internationalization, and various diversification strategies. In particular, since the food service industry employs the franchising strategy the most in the U.S. economy [ 47 ], significant implications of implementing the strategy may exist in relation to the pandemic. Researchers are encouraged to find such implications.

Unit-level analysis

The organizational strategies mentioned above are mainly at the firm level and not at the individual unit level. A majority of the food service business consists of independent and small businesses. Hence, inspecting the effects of the characteristics of the food service business at an individual unit level during the pandemic can provide meaningful and practical implications for food service business owners and operators. An example of such characteristics can be the type of financing. In contrast with large corporations, small food service businesses rely heavily on personal connections to finance (e.g., raising capital from family members and friends) in addition to formal financing (i.e., loans from financial institutions). These different types of financing may imply certain capabilities or lack of them in owners and consequently suggest some anticipatory outcomes during the pandemic, such as a high likelihood of suffering from poor performance and business failure. Thus, these issues should be researched to gain a better understanding of the food service business during the COVID-19 pandemic.

The COVID-19 pandemic has resulted in tremendous changes in the overall economy and society. In the food service industry, the ways people order has shifted mostly to non-human contact or untact methods, such as online orders and drive-through orders. The consumption of particular products, such as HMR and meal-kit, has also increased explosively. Cooking and serving robots have been extensively adopted to prevent human contact and reduce labor costs. The COVID-19 situation has also caused serious issues in environmental protection. In terms of research implications, COVID-19 poses great challenges and provides opportunities. This study discusses these challenges and opportunities from three perspectives: consumer, employee, and organizational strategy perspectives.

Conflict of Interest: The authors declare no potential conflicts of interests.

Author Contributions:

  • Conceptualization: Ham S, Lee, S.
  • Investigation: Ham S, Lee S.
  • Supervision: Ham S, Lee S.
  • Writing - original draft: Ham S, Lee S.
  • Writing - review & editing: Ham S, Lee S.

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  • Volume 10, Issue 11
  • The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA study): a protocol study
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  • http://orcid.org/0000-0001-5621-1833 Adrian I Espiritu 1 , 2 ,
  • http://orcid.org/0000-0003-1135-6400 Marie Charmaine C Sy 1 ,
  • http://orcid.org/0000-0002-1241-8805 Veeda Michelle M Anlacan 1 ,
  • http://orcid.org/0000-0001-5317-7369 Roland Dominic G Jamora 1
  • 1 Department of Neurosciences , College of Medicine and Philippine General Hospital, University of the Philippines Manila , Manila , Philippines
  • 2 Department of Clinical Epidemiology, College of Medicine , University of the Philippines Manila , Manila , Philippines
  • Correspondence to Dr Adrian I Espiritu; aiespiritu{at}up.edu.ph

Introduction The SARS-CoV-2, virus that caused the COVID-19 global pandemic, possesses a neuroinvasive potential. Patients with COVID-19 infection present with neurological signs and symptoms aside from the usual respiratory affectation. Moreover, COVID-19 is associated with several neurological diseases and complications, which may eventually affect clinical outcomes.

Objectives The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA) study investigators will conduct a nationwide, multicentre study involving 37 institutions that aims to determine the neurological manifestations and factors associated with clinical outcomes in COVID-19 infection.

Methodology and analysis This is a retrospective cohort study (comparative between patients with and without neurological manifestations) via medical chart review involving adult patients with COVID-19 infection. Sample size was determined at 1342 patients. Demographic, clinical and neurological profiles will be obtained and summarised using descriptive statistics. Student’s t-test for two independent samples and χ 2 test will be used to determine differences between distributions. HRs and 95% CI will be used as an outcome measure. Kaplan-Meier curves will be constructed to plot the time to onset of mortality (survival), respiratory failure, intensive care unit (ICU) admission, duration of ventilator dependence, length of ICU stay and length of hospital stay. The log-rank test will be employed to compare the Kaplan-Meier curves. Stratified analysis will be performed to identify confounders and effects modifiers. To compute for adjusted HR with 95% CI, crude HR of outcomes will be adjusted according to the prespecified possible confounders. Cox proportional regression models will be used to determine significant factors of outcomes. Testing for goodness of fit will also be done using Hosmer-Lemeshow test. Subgroup analysis will be performed for proven prespecified effect modifiers. The effects of missing data and outliers will also be evaluated in this study.

Ethics and dissemination This protocol was approved by the Single Joint Research Ethics Board of the Philippine Department of Health (SJREB-2020–24) and the institutional review board of the different study sites. The dissemination of results will be conducted through scientific/medical conferences and through journal publication. The lay versions of the results may be provided on request.

Trial registration number NCT04386083 .

  • adult neurology
  • epidemiology

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Strengths and limitations of this study

The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms Study is a nationwide, multicentre, retrospective, cohort study with 37 Philippine sites.

Full spectrum of neurological manifestations of COVID-19 will be collected.

Retrospective gathering of data offers virtually no risk of COVID-19 infection to data collectors.

Data from COVID-19 patients who did not go to the hospital are unobtainable.

Recoding bias is inherent due to the retrospective nature of the study.


The COVID-19 has been identified as the cause of an outbreak of respiratory illness in Wuhan, Hubei Province, China, in December 2019. 1 The COVID-19 pandemic has reached the Philippines with most of its cases found in the National Capital Region (NCR). 2 The major clinical features of COVID-19 include fever, cough, shortness of breath, myalgia, headache and diarrhoea. 3 The outcomes of this disease lead to prolonged hospital stay, intensive care unit (ICU) admission, dependence on invasive mechanical ventilation, respiratory failure and mortality. 4 The specific pathogen that causes this clinical syndrome has been named SARS-CoV-2, which is phylogenetically similar to SARS-CoV. 4 Like the SARS-CoV strain, SARS-CoV-2 may possess a similar neuroinvasive potential. 5

A study on cases with COVID-19 found that about 36.4% of patients displayed neurological manifestations of the central nervous system (CNS) and peripheral nervous system (PNS). 6 The associated spectrum of symptoms and signs were substantially broad such as altered mental status, headache, cognitive impairment, agitation, dysexecutive syndrome, seizures, corticospinal tract signs, dysgeusia, extraocular movement abnormalities and myalgia. 7–12 Several reports were published on neurological disorders associated with patients with COVID-19, including cerebrovascular disorders, encephalopathy, hypoxic brain injury, frequent convulsive seizures and inflammatory CNS syndromes like encephalitis, meningitis, acute disseminated encephalomyelitis and Guillain-Barre syndrome. 7–16 However, the estimates of the occurrences of these manifestations were based on studies with a relatively small sample size. Furthermore, the current description of COVID-19 neurological features are hampered to some extent by exceedingly variable reporting; thus, defining causality between this infection and certain neurological manifestations is crucial since this may lead to considerable complications. 17 An Italian observational study protocol on neurological manifestations has also been published to further document and corroborate these findings. 18

Epidemiological data on the proportions and spectrum of non-respiratory symptoms and complications may be essential to increase the recognition of clinicians of the possibility of COVID-19 infection in the presence of other symptoms, particularly neurological manifestations. With this information, the probabilities of diagnosing COVID-19 disease may be strengthened depending on the presence of certain neurological manifestations. Furthermore, knowledge of other unrecognised symptoms and complications may allow early diagnosis that may permit early institution of personal protective equipment and proper contact precautions. Lastly, the presence of neurological manifestations may be used for estimating the risk of certain important clinical outcomes for better and well-informed clinical decisions in patients with COVID-19 disease.

To address this lack of important information in the overall management of patients with COVID-19, we organised a research study entitled ‘The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA Study)’.

This quantitative, retrospective cohort, multicentre study aims: (1) to determine the demographic, clinical and neurological profile of patients with COVID-19 disease in the Philippines; (2) to determine the frequency of neurological symptoms and new-onset neurological disorders/complications in patients with COVID-19 disease; (3) to determine the neurological manifestations that are significant factors of mortality, respiratory failure, duration of ventilator dependence, ICU admission, length of ICU stay and length of hospital stay among patients with COVID-19 disease; (4) to determine if there is significant difference between COVID-19 patients with neurological manifestations compared with those COVID-19 patients without neurological manifestations in terms of mortality, respiratory failure, duration of ventilator dependence, ICU admission, length of ICU stay and length of hospital stay; and (5) to determine the likelihood of mortality, respiratory failure and ICU admission, including the likelihood of longer duration of ventilator dependence and length of ICU and hospital stay in COVID-19 patients with neurological manifestations compared with those without neurological manifestations.

Scope, limitations and delimitations

The study will include confirmed cases of COVID-19 from the 37 participating institutions in the Philippines. Every country has its own healthcare system, whose level of development and strategies ultimately affect patient outcomes. Thus, the results of this study cannot be accurately generalised to other settings. In addition, patients with ages ≤18 years will be excluded in from this study. These younger patients may have different characteristics and outcomes; therefore, yielded estimates for adults in this study may not be applicable to this population subgroup. Moreover, this study will collect data from the patient records of patients with COVID-19; thus, data from patients with mild symptoms who did not go to the hospital and those who had spontaneous resolution of symptoms despite true infection with COVID-19 are unobtainable.


To improve the quality of reporting of this study, the guidelines issued by the Strengthening the Reporting of Observational Studies in Epidemiology Initiative will be followed. 19

Study design

The study will be conducted using a retrospective cohort (comparative) design (see figure 1 ).

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Schematic diagram of the study flow.

Study sites and duration

We will conduct a nationwide, multicentre study involving 37 institutions in the Philippines (see figure 2 ). Most of these study sites can be found in the NCR, which remains to be the epicentre of the COVID-19 pandemic. 2 We will collect data for 6 months after institutional review board approval for every site.

Location of 37 study sites of the Philippine CORONA study.

Patient selection and cohort description

The cases will be identified using the designated COVID-19 censuses of all the participating centres. A total enumeration of patients with confirmed COVID-19 disease will be done in this study.

The cases identified should satisfy the following inclusion criteria: (A) adult patients at least 19 years of age; (B) cases confirmed by testing approved patient samples (ie, nasal swab, sputum and bronchoalveolar lavage fluid) employing real-time reverse transcription PCR (rRT-PCR) 20 from COVID-19 testing centres accredited by the Department of Health (DOH) of the Philippines, with clinical symptoms and signs attributable to COVID-19 disease (ie, respiratory as well as non-respiratory clinical signs and symptoms) 21 ; and (C) cases with disposition (ie, discharged stable/recovered, home/discharged against medical advice, transferred to other hospital or died) at the end of the study period. Cases with conditions or diseases caused by other organisms (ie, bacteria, other viruses, fungi and so on) or caused by other pathologies unrelated to COVID-19 disease (ie, trauma) will be excluded.

The first cohort will involve patients with confirmed COVID-19 infection who presented with any neurological manifestation/s (ie, symptoms or complications/disorder). The comparator cohort will compose of patients with confirmed COVID-19 infection without neurological manifestation/s.

Sample size calculation

We looked into the mortality outcome measure for the purposes of sample size computation. Following the cohort study of Khaledifar et al , 22 the sample size was calculated using the following parameters: two-sided 95% significance level (1 – α); 80% power (1 – β); unexposed/exposed ratio of 1; 5% of unexposed with outcome (case fatality rate from COVID19-Philippines Dashboard Tracker (PH) 23 as of 8 April 2020); and assumed risk ratio 2 (to see a two-fold increase in risk of mortality when neurological symptoms are present).

When these values were plugged in to the formula for cohort studies, 24 a minimum sample size of 1118 is required. To account for possible incomplete data, the sample was adjusted for 20% more. This means that the total sample size required is 1342 patients, which will be gathered from the participating centres.

Data collection

We formulated an electronic data collection form using Epi Info Software (V. The forms will be pilot-tested, and a formal data collection workshop will be conducted to ensure collection accuracy. The data will be obtained from the review of the medical records.

The following pertinent data will be obtained: (A) demographic data; (B) other clinical profile data/comorbidities; (C) neurological history; (D) date of illness onset; (E) respiratory and constitutional symptoms associated with COVID-19; (F) COVID-19 disease severity 25 at nadir; (G) data if neurological manifestation/s were present at onset prior to respiratory symptoms and the specific neurological manifestation/s present at onset; (H) neurological symptoms; (i) date of neurological symptom onset; (J) new-onset neurological disorders or complications; (K) date of new neurological disorder or complication onset; (L) imaging done; (M) cerebrospinal fluid analysis; (N) electrophysiological studies; (O) treatment given; (P) antibiotics given; (Q) neurological interventions given; (R) date of mortality and cause/s of mortality; (S) date of respiratory failure onset, date of mechanical ventilator cessation and cause/s of respiratory failure; (T) date of first day of ICU admission, date of discharge from ICU and indication/s for ICU admission; (U) other neurological outcomes at discharge; (V) date of hospital discharge; and (W) final disposition. See table 1 for the summary of the data to be collected for this study.

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Data to be collected in this study

Main outcomes considered

The following patient outcomes will be considered for this study:

Mortality (binary outcome): defined as the patients with confirmed COVID-19 who died.

Respiratory failure (binary outcome): defined as the patients with confirmed COVID-19 who experienced clinical symptoms and signs of respiratory insufficiency. Clinically, this condition may manifest as tachypnoea/sign of increased work of breathing (ie, respiratory rate of ≥22), abnormal blood gases (ie, hypoxaemia as evidenced by partial pressure of oxygen (PaO 2 ) <60 or hypercapnia by partial pressure of carbon dioxide of >45), or requiring oxygen supplementation (ie, PaO 2 <60 or ratio of PaO 2 /fraction of inspired oxygen (P/F ratio)) <300).

Duration of ventilator dependence (continuous outcome): defined as the number of days from initiation of assisted ventilation to cessation of mechanical ventilator use.

ICU admission (binary outcome): defined as the patients with confirmed COVID-19 admitted to an ICU or ICU-comparable setting.

Length of ICU stay (continuous outcome): defined as the number of days admitted in the ICU or ICU-comparable setting.

Length of hospital stay (continuous outcome): defined as the number of days from admission to discharge.

Data analysis plan

Statistical analysis will be performed using Stata V.

Demographic, clinical and neurological profiles will be summarised using descriptive statistics, in which categorical variables will be expressed as frequencies with corresponding percentages, and continuous variables will be pooled using means (SD).

Student’s t-test for two independent samples and χ 2 test will be used to determine differences between distributions.

HRs and 95% CI will be used as an outcome measure. Kaplan-Meier curves will be constructed to plot the time to onset of mortality (survival), respiratory failure, ICU admission, duration of ventilator dependence (recategorised binary form), length of ICU stay (recategorised binary form) and length of hospital stay (recategorised binary form). Log-rank test will be employed to compare the Kaplan-Meier curves. Stratified analysis will be performed to identify confounders and effects modifiers. To compute for adjusted HR with 95% CI, crude HR of outcomes at discrete time points will be adjusted for prespecified possible confounders such as age, history of cardiovascular or cerebrovascular disease, hypertension, diabetes mellitus, and respiratory disease, COVID-19 disease severity at nadir, and other significant confounding factors.

Cox proportional regression models will be used to determine significant factors of outcomes. Testing for goodness of fit will be done using Hosmer-Lemeshow test. Likelihood ratio tests and other information criteria (Akaike Information Criterion or Bayesian Information Criterion) will be used to refine the final model. Statistical significance will be considered if the 95% CI of HR or adjusted HR did not include the number one. A p value <0.05 (two tailed) is set for other analyses.

Subgroup analyses will be performed for proven prespecified effect modifiers. The following variables will be considered for subgroup analyses: age (19–64 years vs ≥65 years), sex, body mass index (<18.5 vs 18.5–22.9 vs ≥23 kg/m 2 ), with history of cardiovascular or cerebrovascular disease (presence or absence), hypertension (presence or absence), diabetes mellitus (presence or absence), respiratory disease (presence or absence), smoking status (smoker or non-smoker) and COVID-19 disease severity (mild, severe or critical disease).

The effects of missing data will be explored. All efforts will be exerted to minimise missing and spurious data. Validity of the submitted electronic data collection will be monitored and reviewed weekly to prevent missing or inaccurate input of data. Multiple imputations will be performed for missing data when possible. To check for robustness of results, analysis done for patients with complete data will be compared with the analysis with the imputed data.

The effects of outliers will also be assessed. Outliers will be assessed by z-score or boxplot. A cut-off of 3 SD from the mean can also be used. To check for robustness of results, analysis done with outliers will be compared with the analysis without the outliers.

Study organisational structure

A steering committee (AIE, MCCS, VMMA and RDGJ) was formed to direct and provide appropriate scientific, technical and methodological assistance to study site investigators and collaborators (see figure 3 ). Central administrative coordination, data management, administrative support, documentation of progress reports, data analyses and interpretation and journal publication are the main responsibilities of the steering committee. Study site investigators and collaborators are responsible for the proper collection and recording of data including the duty to maintain the confidentiality of information and the privacy of all identified patients for all the phases of the research processes.

Organisational structure of oversight of the Philippine CORONA Study.

This section is highlighted as part of the required formatting amendments by the Journal.

Ethics and dissemination

This research will adhere to the Philippine National Ethical Guidelines for Health and Health-related Research 2017. 26 This study is an observational, cohort study and will not allocate any type of intervention. The medical records of the identified patients will be reviewed retrospectively. To protect the privacy of the participant, the data collection forms will not contain any information (ie, names and institutional patient number) that could determine the identity of the patients. A sequential code will be recorded for each patient in the following format: AAA-BBB where AAA will pertain to the three-digit code randomly assigned to each study site; BBB will pertain to the sequential case number assigned by each study site. Each participating centre will designate a password-protected laptop for data collection; the password is known only to the study site.

This protocol was approved by the following institutional review boards: Single Joint Research Ethics Board of the DOH, Philippines (SJREB-2020-24); Asian Hospital and Medical Center, Muntinlupa City (2020- 010-A); Baguio General Hospital and Medical Center (BGHMC), Baguio City (BGHMC-ERC-2020-13); Cagayan Valley Medical Center (CVMC), Tuguegarao City; Capitol Medical Center, Quezon City; Cardinal Santos Medical Center (CSMC), San Juan City (CSMC REC 2020-020); Chong Hua Hospital, Cebu City (IRB 2420–04); De La Salle Medical and Health Sciences Institute (DLSMHSI), Cavite (2020-23-02-A); East Avenue Medical Center (EAMC), Quezon City (EAMC IERB 2020-38); Jose R. Reyes Memorial Medical Center, Manila; Jose B. Lingad Memorial Regional Hospital, San Fernando, Pampanga; Dr. Jose N. Rodriguez Memorial Hospital, Caloocan City; Lung Center of the Philippines (LCP), Quezon City (LCP-CT-010–2020); Manila Doctors Hospital, Manila (MDH IRB 2020-006); Makati Medical Center, Makati City (MMC IRB 2020–054); Manila Medical Center, Manila (MMERC 2020-09); Northern Mindanao Medical Center, Cagayan de Oro City (025-2020); Quirino Memorial Medical Center (QMMC), Quezon City (QMMC REB GCS 2020-28); Ospital ng Makati, Makati City; University of the Philippines – Philippine General Hospital (UP-PGH), Manila (2020-314-01 SJREB); Philippine Heart Center, Quezon City; Research Institute for Tropical Medicine, Muntinlupa City (RITM IRB 2020-16); San Lazaro Hospital, Manila; San Juan De Dios Educational Foundation Inc – Hospital, Pasay City (SJRIB 2020-0006); Southern Isabela Medical Center, Santiago City (2020-03); Southern Philippines Medical Center (SPMC), Davao City (P20062001); St. Luke’s Medical Center, Quezon City (SL-20116); St. Luke’s Medical Center, Bonifacio Global City, Taguig City (SL-20116); Southern Philippines Medical Center, Davao City; The Medical City, Pasig City; University of Santo Tomas Hospital, Manila (UST-REC-2020-04-071-MD); University of the East Ramon Magsaysay Memorial Medical Center, Inc, Quezon City (0835/E/2020/063); Veterans Memorial Medical Center (VMMC), Quezon City (VMMC-2020-025) and Vicente Sotto Memorial Medical Center, Cebu City (VSMMC-REC-O-2020–048).

The dissemination of results will be conducted through scientific/medical conferences and through journal publication. Only the aggregate results of the study shall be disseminated. The lay versions of the results may be provided on request.

Protocol registration and technical review approval

This protocol was registered in the ClinicalTrials.gov website. It has received technical review board approvals from the Department of Neurosciences, Philippine General Hospital and College of Medicine, University of the Philippines Manila, from the Cardinal Santos Medical Center (San Juan City) and from the Research Center for Clinical Epidemiology and Biostatistics, De La Salle Medical and Health Sciences Institute (Dasmariñas, Cavite).


We would like to thank Almira Abigail Doreen O Apor, MD, of the Department of Neurosciences, Philippine General Hospital, Philippines, for illustrating figure 2 for this publication.

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VMMA and RDGJ are joint senior authors.

AIE and MCCS are joint first authors.

Twitter @neuroaidz, @JamoraRoland

Collaborators The Philippine CORONA Study Group Collaborators: Maritoni C Abbariao, Joshua Emmanuel E Abejero, Ryndell G Alava, Robert A Barja, Dante P Bornales, Maria Teresa A Cañete, Ma. Alma E Carandang-Concepcion, Joseree-Ann S Catindig, Maria Epifania V Collantes, Evram V Corral, Ma. Lourdes P Corrales-Joson, Romulus Emmanuel H Cruz, Marita B Dantes, Ma. Caridad V Desquitado, Cid Czarina E Diesta, Carissa Paz C Dioquino, Maritzie R Eribal, Romulo U Esagunde, Rosalina B Espiritu-Picar, Valmarie S Estrada, Manolo Kristoffer C Flores, Dan Neftalie A Juangco, Muktader A Kalbi, Annabelle Y Lao-Reyes, Lina C Laxamana, Corina Maria Socorro A Macalintal, Maria Victoria G Manuel, Jennifer Justice F Manzano, Ma. Socorro C Martinez, Generaldo D Maylem, Marc Conrad C Molina, Marietta C Olaivar, Marissa T Ong, Arnold Angelo M Pineda, Joanne B Robles, Artemio A Roxas Jr, Jo Ann R Soliven, Arturo F Surdilla, Noreen Jhoanna C Tangcuangco-Trinidad, Rosalia A Teleg, Jarungchai Anton S Vatanagul and Maricar P Yumul.

Contributors All authors conceived the idea and wrote the initial drafts and revisions of the protocol. All authors made substantial contributions in this protocol for intellectual content.

Funding Philippine Neurological Association (Grant/Award Number: N/A). Expanded Hospital Research Office, Philippine General Hospital (Grant/Award Number: N/A).

Disclaimer Our funding sources had no role in the design of the protocol, and will not be involved during the methodological execution, data analyses and interpretation and decision to submit or to publish the study results.

Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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