impact of covid 19 on lifestyle essay

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

Joint statement by ilo, fao, ifad and who.

The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an unprecedented challenge to public health, food systems and the world of work. The economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty, while the number of undernourished people, currently estimated at nearly 690 million, could increase by up to 132 million by the end of the year.

Millions of enterprises face an existential threat. Nearly half of the world’s 3.3 billion global workforce are at risk of losing their livelihoods. Informal economy workers are particularly vulnerable because the majority lack social protection and access to quality health care and have lost access to productive assets. Without the means to earn an income during lockdowns, many are unable to feed themselves and their families. For most, no income means no food, or, at best, less food and less nutritious food.

The pandemic has been affecting the entire food system and has laid bare its fragility. Border closures, trade restrictions and confinement measures have been preventing farmers from accessing markets, including for buying inputs and selling their produce, and agricultural workers from harvesting crops, thus disrupting domestic and international food supply chains and reducing access to healthy, safe and diverse diets. The pandemic has decimated jobs and placed millions of livelihoods at risk. As breadwinners lose jobs, fall ill and die, the food security and nutrition of millions of women and men are under threat, with those in low-income countries, particularly the most marginalized populations, which include small-scale farmers and indigenous peoples, being hardest hit.

Millions of agricultural workers – waged and self-employed – while feeding the world, regularly face high levels of working poverty, malnutrition and poor health, and suffer from a lack of safety and labour protection as well as other types of abuse. With low and irregular incomes and a lack of social support, many of them are spurred to continue working, often in unsafe conditions, thus exposing themselves and their families to additional risks. Further, when experiencing income losses, they may resort to negative coping strategies, such as distress sale of assets, predatory loans or child labour. Migrant agricultural workers are particularly vulnerable, because they face risks in their transport, working and living conditions and struggle to access support measures put in place by governments. Guaranteeing the safety and health of all agri-food workers – from primary producers to those involved in food processing, transport and retail, including street food vendors – as well as better incomes and protection, will be critical to saving lives and protecting public health, people’s livelihoods and food security.

In the COVID-19 crisis food security, public health, and employment and labour issues, in particular workers’ health and safety, converge. Adhering to workplace safety and health practices and ensuring access to decent work and the protection of labour rights in all industries will be crucial in addressing the human dimension of the crisis. Immediate and purposeful action to save lives and livelihoods should include extending social protection towards universal health coverage and income support for those most affected. These include workers in the informal economy and in poorly protected and low-paid jobs, including youth, older workers, and migrants. Particular attention must be paid to the situation of women, who are over-represented in low-paid jobs and care roles. Different forms of support are key, including cash transfers, child allowances and healthy school meals, shelter and food relief initiatives, support for employment retention and recovery, and financial relief for businesses, including micro, small and medium-sized enterprises. In designing and implementing such measures it is essential that governments work closely with employers and workers.

Countries dealing with existing humanitarian crises or emergencies are particularly exposed to the effects of COVID-19. Responding swiftly to the pandemic, while ensuring that humanitarian and recovery assistance reaches those most in need, is critical.

Now is the time for global solidarity and support, especially with the most vulnerable in our societies, particularly in the emerging and developing world. Only together can we overcome the intertwined health and social and economic impacts of the pandemic and prevent its escalation into a protracted humanitarian and food security catastrophe, with the potential loss of already achieved development gains.

We must recognize this opportunity to build back better, as noted in the Policy Brief issued by the United Nations Secretary-General. We are committed to pooling our expertise and experience to support countries in their crisis response measures and efforts to achieve the Sustainable Development Goals. We need to develop long-term sustainable strategies to address the challenges facing the health and agri-food sectors. Priority should be given to addressing underlying food security and malnutrition challenges, tackling rural poverty, in particular through more and better jobs in the rural economy, extending social protection to all, facilitating safe migration pathways and promoting the formalization of the informal economy.

We must rethink the future of our environment and tackle climate change and environmental degradation with ambition and urgency. Only then can we protect the health, livelihoods, food security and nutrition of all people, and ensure that our ‘new normal’ is a better one.

Media Contacts

Kimberly Chriscaden

Communications Officer World Health Organization

Nutrition and Food Safety (NFS) and COVID-19

Read these 12 moving essays about life during coronavirus

Artists, novelists, critics, and essayists are writing the first draft of history.

by Alissa Wilkinson

The world is grappling with an invisible, deadly enemy, trying to understand how to live with the threat posed by a virus . For some writers, the only way forward is to put pen to paper, trying to conceptualize and document what it feels like to continue living as countries are under lockdown and regular life seems to have ground to a halt.

So as the coronavirus pandemic has stretched around the world, it’s sparked a crop of diary entries and essays that describe how life has changed. Novelists, critics, artists, and journalists have put words to the feelings many are experiencing. The result is a first draft of how we’ll someday remember this time, filled with uncertainty and pain and fear as well as small moments of hope and humanity.

The Vox guide to navigating the coronavirus crisis

At the New York Review of Books, Ali Bhutto writes that in Karachi, Pakistan, the government-imposed curfew due to the virus is “eerily reminiscent of past military clampdowns”:

Beneath the quiet calm lies a sense that society has been unhinged and that the usual rules no longer apply. Small groups of pedestrians look on from the shadows, like an audience watching a spectacle slowly unfolding. People pause on street corners and in the shade of trees, under the watchful gaze of the paramilitary forces and the police.

His essay concludes with the sobering note that “in the minds of many, Covid-19 is just another life-threatening hazard in a city that stumbles from one crisis to another.”

Writing from Chattanooga, novelist Jamie Quatro documents the mixed ways her neighbors have been responding to the threat, and the frustration of conflicting direction, or no direction at all, from local, state, and federal leaders:

Whiplash, trying to keep up with who’s ordering what. We’re already experiencing enough chaos without this back-and-forth. Why didn’t the federal government issue a nationwide shelter-in-place at the get-go, the way other countries did? What happens when one state’s shelter-in-place ends, while others continue? Do states still under quarantine close their borders? We are still one nation, not fifty individual countries. Right?

A syllabus for the end of the world

Award-winning photojournalist Alessio Mamo, quarantined with his partner Marta in Sicily after she tested positive for the virus, accompanies his photographs in the Guardian of their confinement with a reflection on being confined :

The doctors asked me to take a second test, but again I tested negative. Perhaps I’m immune? The days dragged on in my apartment, in black and white, like my photos. Sometimes we tried to smile, imagining that I was asymptomatic, because I was the virus. Our smiles seemed to bring good news. My mother left hospital, but I won’t be able to see her for weeks. Marta started breathing well again, and so did I. I would have liked to photograph my country in the midst of this emergency, the battles that the doctors wage on the frontline, the hospitals pushed to their limits, Italy on its knees fighting an invisible enemy. That enemy, a day in March, knocked on my door instead.

In the New York Times Magazine, deputy editor Jessica Lustig writes with devastating clarity about her family’s life in Brooklyn while her husband battled the virus, weeks before most people began taking the threat seriously:

At the door of the clinic, we stand looking out at two older women chatting outside the doorway, oblivious. Do I wave them away? Call out that they should get far away, go home, wash their hands, stay inside? Instead we just stand there, awkwardly, until they move on. Only then do we step outside to begin the long three-block walk home. I point out the early magnolia, the forsythia. T says he is cold. The untrimmed hairs on his neck, under his beard, are white. The few people walking past us on the sidewalk don’t know that we are visitors from the future. A vision, a premonition, a walking visitation. This will be them: Either T, in the mask, or — if they’re lucky — me, tending to him.

Essayist Leslie Jamison writes in the New York Review of Books about being shut away alone in her New York City apartment with her 2-year-old daughter since she became sick:

The virus. Its sinewy, intimate name. What does it feel like in my body today? Shivering under blankets. A hot itch behind the eyes. Three sweatshirts in the middle of the day. My daughter trying to pull another blanket over my body with her tiny arms. An ache in the muscles that somehow makes it hard to lie still. This loss of taste has become a kind of sensory quarantine. It’s as if the quarantine keeps inching closer and closer to my insides. First I lost the touch of other bodies; then I lost the air; now I’ve lost the taste of bananas. Nothing about any of these losses is particularly unique. I’ve made a schedule so I won’t go insane with the toddler. Five days ago, I wrote Walk/Adventure! on it, next to a cut-out illustration of a tiger—as if we’d see tigers on our walks. It was good to keep possibility alive.

At Literary Hub, novelist Heidi Pitlor writes about the elastic nature of time during her family’s quarantine in Massachusetts:

During a shutdown, the things that mark our days—commuting to work, sending our kids to school, having a drink with friends—vanish and time takes on a flat, seamless quality. Without some self-imposed structure, it’s easy to feel a little untethered. A friend recently posted on Facebook: “For those who have lost track, today is Blursday the fortyteenth of Maprilay.” ... Giving shape to time is especially important now, when the future is so shapeless. We do not know whether the virus will continue to rage for weeks or months or, lord help us, on and off for years. We do not know when we will feel safe again. And so many of us, minus those who are gifted at compartmentalization or denial, remain largely captive to fear. We may stay this way if we do not create at least the illusion of movement in our lives, our long days spent with ourselves or partners or families.

What day is it today?

Novelist Lauren Groff writes at the New York Review of Books about trying to escape the prison of her fears while sequestered at home in Gainesville, Florida:

Some people have imaginations sparked only by what they can see; I blame this blinkered empiricism for the parks overwhelmed with people, the bars, until a few nights ago, thickly thronged. My imagination is the opposite. I fear everything invisible to me. From the enclosure of my house, I am afraid of the suffering that isn’t present before me, the people running out of money and food or drowning in the fluid in their lungs, the deaths of health-care workers now growing ill while performing their duties. I fear the federal government, which the right wing has so—intentionally—weakened that not only is it insufficient to help its people, it is actively standing in help’s way. I fear we won’t sufficiently punish the right. I fear leaving the house and spreading the disease. I fear what this time of fear is doing to my children, their imaginations, and their souls.

At ArtForum , Berlin-based critic and writer Kristian Vistrup Madsen reflects on martinis, melancholia, and Finnish artist Jaakko Pallasvuo’s 2018 graphic novel Retreat , in which three young people exile themselves in the woods:

In melancholia, the shape of what is ending, and its temporality, is sprawling and incomprehensible. The ambivalence makes it hard to bear. The world of Retreat is rendered in lush pink and purple watercolors, which dissolve into wild and messy abstractions. In apocalypse, the divisions established in genesis bleed back out. My own Corona-retreat is similarly soft, color-field like, each day a blurred succession of quarantinis, YouTube–yoga, and televized press conferences. As restrictions mount, so does abstraction. For now, I’m still rooting for love to save the world.

At the Paris Review , Matt Levin writes about reading Virginia Woolf’s novel The Waves during quarantine:

A retreat, a quarantine, a sickness—they simultaneously distort and clarify, curtail and expand. It is an ideal state in which to read literature with a reputation for difficulty and inaccessibility, those hermetic books shorn of the handholds of conventional plot or characterization or description. A novel like Virginia Woolf’s The Waves is perfect for the state of interiority induced by quarantine—a story of three men and three women, meeting after the death of a mutual friend, told entirely in the overlapping internal monologues of the six, interspersed only with sections of pure, achingly beautiful descriptions of the natural world, a day’s procession and recession of light and waves. The novel is, in my mind’s eye, a perfectly spherical object. It is translucent and shimmering and infinitely fragile, prone to shatter at the slightest disturbance. It is not a book that can be read in snatches on the subway—it demands total absorption. Though it revels in a stark emotional nakedness, the book remains aloof, remote in its own deep self-absorption.

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In an essay for the Financial Times, novelist Arundhati Roy writes with anger about Indian Prime Minister Narendra Modi’s anemic response to the threat, but also offers a glimmer of hope for the future:

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.

From Boston, Nora Caplan-Bricker writes in The Point about the strange contraction of space under quarantine, in which a friend in Beirut is as close as the one around the corner in the same city:

It’s a nice illusion—nice to feel like we’re in it together, even if my real world has shrunk to one person, my husband, who sits with his laptop in the other room. It’s nice in the same way as reading those essays that reframe social distancing as solidarity. “We must begin to see the negative space as clearly as the positive, to know what we don’t do is also brilliant and full of love,” the poet Anne Boyer wrote on March 10th, the day that Massachusetts declared a state of emergency. If you squint, you could almost make sense of this quarantine as an effort to flatten, along with the curve, the distinctions we make between our bonds with others. Right now, I care for my neighbor in the same way I demonstrate love for my mother: in all instances, I stay away. And in moments this month, I have loved strangers with an intensity that is new to me. On March 14th, the Saturday night after the end of life as we knew it, I went out with my dog and found the street silent: no lines for restaurants, no children on bicycles, no couples strolling with little cups of ice cream. It had taken the combined will of thousands of people to deliver such a sudden and complete emptiness. I felt so grateful, and so bereft.

And on his own website, musician and artist David Byrne writes about rediscovering the value of working for collective good , saying that “what is happening now is an opportunity to learn how to change our behavior”:

In emergencies, citizens can suddenly cooperate and collaborate. Change can happen. We’re going to need to work together as the effects of climate change ramp up. In order for capitalism to survive in any form, we will have to be a little more socialist. Here is an opportunity for us to see things differently — to see that we really are all connected — and adjust our behavior accordingly. Are we willing to do this? Is this moment an opportunity to see how truly interdependent we all are? To live in a world that is different and better than the one we live in now? We might be too far down the road to test every asymptomatic person, but a change in our mindsets, in how we view our neighbors, could lay the groundwork for the collective action we’ll need to deal with other global crises. The time to see how connected we all are is now.

The portrait these writers paint of a world under quarantine is multifaceted. Our worlds have contracted to the confines of our homes, and yet in some ways we’re more connected than ever to one another. We feel fear and boredom, anger and gratitude, frustration and strange peace. Uncertainty drives us to find metaphors and images that will let us wrap our minds around what is happening.

Yet there’s no single “what” that is happening. Everyone is contending with the pandemic and its effects from different places and in different ways. Reading others’ experiences — even the most frightening ones — can help alleviate the loneliness and dread, a little, and remind us that what we’re going through is both unique and shared by all.

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In Their Own Words, Americans Describe the Struggles and Silver Linings of the COVID-19 Pandemic

The outbreak has dramatically changed americans’ lives and relationships over the past year. we asked people to tell us about their experiences – good and bad – in living through this moment in history..

Pew Research Center has been asking survey questions over the past year about Americans’ views and reactions to the COVID-19 pandemic. In August, we gave the public a chance to tell us in their own words how the pandemic has affected them in their personal lives. We wanted to let them tell us how their lives have become more difficult or challenging, and we also asked about any unexpectedly positive events that might have happened during that time.

The vast majority of Americans (89%) mentioned at least one negative change in their own lives, while a smaller share (though still a 73% majority) mentioned at least one unexpected upside. Most have experienced these negative impacts and silver linings simultaneously: Two-thirds (67%) of Americans mentioned at least one negative and at least one positive change since the pandemic began.

For this analysis, we surveyed 9,220 U.S. adults between Aug. 31-Sept. 7, 2020. Everyone who completed the survey is a member of Pew Research Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Respondents to the survey were asked to describe in their own words how their lives have been difficult or challenging since the beginning of the coronavirus outbreak, and to describe any positive aspects of the situation they have personally experienced as well. Overall, 84% of respondents provided an answer to one or both of the questions. The Center then categorized a random sample of 4,071 of their answers using a combination of in-house human coders, Amazon’s Mechanical Turk service and keyword-based pattern matching. The full methodology and questions used in this analysis can be found here.

In many ways, the negatives clearly outweigh the positives – an unsurprising reaction to a pandemic that had killed more than 180,000 Americans at the time the survey was conducted. Across every major aspect of life mentioned in these responses, a larger share mentioned a negative impact than mentioned an unexpected upside. Americans also described the negative aspects of the pandemic in greater detail: On average, negative responses were longer than positive ones (27 vs. 19 words). But for all the difficulties and challenges of the pandemic, a majority of Americans were able to think of at least one silver lining.

Both the negative and positive impacts described in these responses cover many aspects of life, none of which were mentioned by a majority of Americans. Instead, the responses reveal a pandemic that has affected Americans’ lives in a variety of ways, of which there is no “typical” experience. Indeed, not all groups seem to have experienced the pandemic equally. For instance, younger and more educated Americans were more likely to mention silver linings, while women were more likely than men to mention challenges or difficulties.

Here are some direct quotes that reveal how Americans are processing the new reality that has upended life across the country.

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Impact of COVID-19 on Lifestyle, Personal Attitudes, and Mental Health Among Korean Medical Students: Network Analysis of Associated Patterns

Affiliations.

1 Seoul National University Hospital, Seoul, South Korea.
2 Yeongeon Student Support Center, Seoul National University College of Medicine, Seoul, South Korea.
3 Office of Medical Education, Seoul National University College of Medicine, Seoul, South Korea.
4 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
PMID: 34483994
PMCID: PMC8416342
DOI: 10.3389/fpsyt.2021.702092

The current COVID-19 pandemic have affected our daily lifestyle, pressed us with fear of infection, and thereby changed life satisfaction and mental health. The current study investigated influencing cascade of changes during the COVID-19 among the lifestyle, personal attitudes, and life (dis)satisfaction for medical students, using network-based approaches. This cross-sectional survey used self-reports of 454 medical students during June and July of 2020. Depressive mood, anxiety, and intention to drop out of school were observed in 11.9, 18.5, and 38.3% of medical students, respectively. Directed acyclic graph that estimated directional propagation of the COVID-19 in medical students' daily lives initiated from the perception of unexpected event, propagated to nervous and stressed feeling, trouble relaxing, feeling like a failure, and were followed by trouble concentrating, feeling loss of control for situation, and fear of infecting colleagues. These six features were also principal mediators within the intra-individual covariance networks comprised of changed lifestyle, personal attitude, and mental health at COVID-19 pandemic. Psychosocial supports targeting nervousness, trouble relaxing and concentrating, fear of spreading infection to colleagues, feelings of a failure or loss of situational control are required for better mental health of medical students during the COVID-19 pandemic.

Keywords: COVID-19; directed acyclic graph; fear of infection; intra-individual covariance network; lifestyle changes; medical students; mental health.

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Conflict of interest statement

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

A directed acyclic graph of…

A directed acyclic graph of changes in lifestyle, personal attitudes, perceived stress, anxiety,…

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Rank-transformed betweenness centrality calculated from the intra-individual covariance networks of changes in lifestyle,…

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Open access
Published: 25 June 2021

Lifestyle changes during the first wave of the COVID-19 pandemic: a cross-sectional survey in the Netherlands

Esther T. van der Werf 1 , 2 ,
Martine Busch 2 , 3 ,
Miek C. Jong 4 , 5 &
H. J. Rogier Hoenders 2 , 6

BMC Public Health volume 21 , Article number: 1226 ( 2021 ) Cite this article

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During the Covid-19 pandemic the Dutch government implemented its so-called ‘intelligent lockdown’ in which people were urged to leave their homes as little as possible and work from home. This life changing event may have caused changes in lifestyle behaviour, an important factor in the onset and course of diseases. The overarching aim of this study is to determine life-style related changes during the first wave of the COVID-19 pandemic among a representative sample of the adult population in the Netherlands.

Life-style related changes were studied among a random representative sample of the adult population in the Netherlands using an online survey conducted from 22 to 27 May 2020. Differences in COVID-19-related lifestyle changes between Complementary and Alternative Medicine (CAM) users and non-CAM users were determined. The survey included a modified version of the I-CAM-Q and 26 questions on lifestyle related measures, anxiety, and need for support to maintain lifestyle changes.

1004 respondents were included in the study, aged between 18 and 88 years (50.7% females). Changes to a healthier lifestyle were observed in 19.3% of the population, mainly due to a change in diet habits, physical activity and relaxation, of whom 56.2% reported to be motivated to maintain this behaviour change in a post-COVID-19 era. Fewer respondents (12.3%) changed into an unhealthier lifestyle. Multivariable logistic regression analyses revealed that changing into a healthier lifestyle was positively associated with the variables ‘Worried/Anxious getting COVID-19’ (OR: 1.56, 95% C.I. 1.26–1.93), ‘CAM use’ (OR: 2.04, 95% C.I. 1.38–3.02) and ‘stress in relation to financial situation’ (OR: 1.89, 95% C.I. 1.30–2.74). ‘Age’ (OR 18–25: 1.00, OR 25–40: 0.55, 95% C.I. 0.31–0.96, OR 40–55:0.50 95% C.I. 0.28–0.87 OR 55+: 0.1095% C.I. 0.10–0.33), ‘stress in relation to health’ (OR: 2.52, 95% C.I. 1.64–3.86) and ‘stress in relation to the balance work and home’ (OR: 1.69, 95% C.I. 1.11–2.57) were found predicting the change into an unhealthier direction.

These findings suggest that the coronavirus crisis resulted in a healthier lifestyle in one part and, to a lesser extent, in an unhealthier lifestyle in another part of the Dutch population. Further studies are warranted to see whether this behavioural change is maintained over time, and how different lifestyle factors can affect the susceptibility for and the course of COVID-19.

Peer Review reports

The rapid spread of COVID-19 to nearly all parts of the world has posed enormous health, economic, environmental and social challenges worldwide. In the absence of effective drugs or vaccines, social distancing, surgical masks, washing hands and other preventive measures are presented as the only ways to fight the (spread of the) virus. Lockdown is among one of the options suggested by WHO to reduce spread of the virus. Although underreported, preventative strategies such as a healthy lifestyle seem important alternative avenues to fight (the spread of) COVID-19. From a public health perspective, these strategies are very important to consider. Between February 2020 and 1st of June 2021 1.651.780 positive cases and 17,632 deaths has been registered in The Netherlands [ 1 ]. As a response to COVID-19, many countries are using a combination of containment and mitigation activities with the intention of delaying major surges of patients and levelling the demand for hospital beds, while protecting the most vulnerable from infection, including elderly people and those with comorbidities [ 2 ]. In the Netherlands, a so-called “intelligent lockdown” was enforced on 15th of March 2020, with easing of restrictions per 1st of July 2020 [ 3 ]. With the intelligent lockdown, the Dutch Government appealed to the responsibility and self-discipline of citizens to practice 1.5 m social distance, and to maintain home isolation when showing COVID-19-related symptoms. Over the course of several weeks in March and April 2020, additional measures were taken to restrict the further spread of the coronavirus in the Netherlands. These measures included closure of schools, restaurants, certain beaches and parks, and prohibition of spontaneous group gatherings in public spaces.

Due to this intelligent lockdown, a sudden and radical change occurred in the lives and habits of the Dutch population. Life experiences that may greatly influence an individual’s daily routine are referred to as life changing events [ 4 ], defined as “those occurrences, including social, psychological and environmental, which require an adjustment or effect a change in an individual’s pattern of living.” Life changing events may influence lifestyle behaviours for better or worse [ 5 , 6 ]. For instance, Engberg et al. showed that transition to university, having a child, remarriage and mass urban disasters were associated with decreased physical activity levels, while retirement was associated with increased physical activity [ 7 ]. Stressful life events have been correlated with excessive alcohol consumption and alcohol dependence and emotional eating [ 8 ].

Maintaining a healthy nutrition status and level of certain exercise is crucial, especially in a period when the immune system might need to fight back. In fact, subjects with (severe) obesity (BMI ≥ 30 kg/m2) are one of the groups with a higher risk for COVID-19 complications [ 9 , 10 ]. Therefore, losing weight may be one of the strategies to lower the risk of severe illness from COVID-19. Worldwide, authorities and healthcare professional’s recommendations on how to stay healthy during the COVID-19 pandemic, besides taking appropriate hygiene measures, are related to healthy life-style measures such as assuring sufficient sleep, eat plenty of fresh fruits and vegetables, reduce stress and social isolation and stay active [ 11 , 12 ].

The COVID-19 pandemic might motivate people to make healthier choices and adopt a healthier lifestyle. Conversely, COVID-19 control measures such as social distancing and compulsory home isolation can be expected to increase sedentary behaviour and might cause an unhealthy eating and sleeping pattern. For example, the interruption of the daily (work) routine caused by the staying at home (which includes digital-education, working from home, and limitation of outdoors and in-gym physical activity) could result in boredom, which in turn is associated with a greater energy intake [ 13 ]. In addition, hearing or reading continuously about the COVID-19 pandemic and its possible impact from media can be stressful. Stress leads individuals toward overeating, especially ‘comfort foods’ or inactivity [ 14 ]. For future actions it is important to determine the lifestyle changes taken during this COVID-19 pandemic, and what support will be needed to (dis) continue this health behaviour in a post-COVID-19 era.

Previous studies show that Complementary and Alternative Medicine (CAM) users have on average a healthier lifestyle behaviour than non-CAM users, and overall a stronger focus on wellness [ 15 , 16 , 17 , 18 ]. In general, CAM is defined as a group of diverse medical and health care symptoms, practices and products that are not generally considered part of conventional medicine [ 19 ]. Nahin et al. found based on a survey among the US population that engaging in leisure-time physical activity, having consumed alcohol in one’s life but not being a current heavy drinker, and being a former smoker are independently associated with the use of CAM [ 16 ]. Interestingly, reported significantly better health status and healthier behaviours overall (higher rates of physical activity and lower rates of obesity) seems more prominent in adults using CAM for health promotion than those who use CAM as treatment [ 15 ]. The relation between CAM use and lifestyle needs further investigation in various populations.

The overarching aim of this reported study is to investigate life-style related changes during the first wave of the COVID-19 pandemic among a representative sample of the adult population in the Netherlands. Within this aim the following objectives has been framed: i) To determine life-style related changes (healtier/unhealthier) during the first wave of the COVID-19 pandemic; (ii) To identify the (sociodemographic) factors independently associated with changes into lifestyle (healthy/unhealthy); (iii) To explore possible differences in COVID-19-related lifestyle changes between CAM users and non-CAM users, and (iv) To determine the intention to continue lifestyle changes and the required support.

An international cross-sectional survey on CAM use and self-care strategies for prevention and treatment of COVID-19 related symptoms was carried out in Norway, Sweden and the Netherlands in spring 2020. The results of this international survey will be published elsewhere. This online survey consisted of a modified version of the International Questionnaire to Measure Use of Complementary and Alternative Medicine (I-CAM-Q) [ 20 ], and a country specific part on lifestyle for The Netherlands (it is the latter on which this paper reports). The modified I-CAM-Q consisted of four parts, and all parts related to CAM use during the past three COVID-19 pandemic months as did the Dutch part on lifestyle.

The modified I-CAM-Q included questions about visits to conventional and unconventional health care providers, self-management strategies such as use of natural remedies and self-help techniques such as mindfulness used within the last three months. The questions regarding specific therapies were adapted to The Netherlands ( supplementary material ).

The country specific part for the Netherlands included 26 questions divided into three sections on 1) current lifestyle related measures (alcohol use, smoking, daily consumption of certain foods, exercise, sleep, stress and meaning and purpose/spirituality), 2) lifestyle related changes since the COVID-19 outbreak and anxiety (section 1 and 2: 20 questions) and 3) intention to continue lifestyle changes and need for support (6 questions). For this study, we included six aspects of lifestyle with established effects on physical and mental health: nutrition, exercise, sleep, addiction, relaxation and meaning and purpose/spirituality.

In the Netherlands, an online survey was performed between May 22 and May 27, 2020 in collaboration with Ipsos Netherlands. An internal Ipsos tool (ISS) has been used to gather the respondents. The respondents registered into the IIS panel have shared their baseline information such as age,gender, region, and more specific information on education, income and work. From the panel of 45,000 Dutch residents, a representative sample (based on the baseline parameters) was invited to complete the questionnaire until 1000 responses were received (limit set due to costs). Individuals who were reached and refused participation ( n = 3607) were considered non-respondents, leading to a response rate of 22%. The final sample contained 1004 individuals.

Taking into account multiple response biases, the questionnaire was designed as followed: 1) answer options were randomized. Meaning every participant will see the same answer options, but in different order, preventing primacy bias (to decrease the amount of times one answer can be chosen which might lead to survey results being too unfairly weighted towards one option), and 2) questions were formulated in a neutral way when asked about education level, salary, age and gender to prevent prestige/stereotype bias as much as possible. Respondents received a personal link (password/username) to prevent filling in the questionnaire more than one time or any self-selection bias would happen.

Demographic characteristics collected were gender, age, municipality of residence and county, income, and level of education. Income was classified as high (Euro 75,000 >), middle (Euro 25,000 – 74,999) and low income (< Euro 24,999). Education was classified as higher education ((applied) university/ post-doctoral level), secondary education (middle and higher secondary education) and lower education (no school/primary school only/lower secondary education).

All data was anonymously collected and reported. The anonymous nature of the web-survey did not allow to trace in any way sensitive personal data. The study protocol was reviewed by the Medical Ethical Reviewing Committee of Wageningen University. They decided that this study did not fall within the remit of the Dutch Medical Research Involving Human Subjects Act (WMO), and therefore was exempt from further medical ethical review. Informed consent was obtained from all participants and all patients agreed their data to be used for scientific publication. GDPR guidelines were taken into account [ 21 ]. Once completed, each questionnaire was transmitted to the survey platform, and the final database was downloaded.

The current paper reports on the country specific part of the survey using data of the I-CAM-Q, only to categorize users and non-users of CAM. Here, CAM use is defined as all treatments and (self) care strategies that are used in addition or as an alternative to the usual (regular) care of e.g. general practitioner, specialist, dietician, physiotherapist or nurse in the past 3 months.

Statistical analyses

Descriptive statistics like measures of central tendencies, frequencies and proportions were used to evaluate the responses. Data are represented as number and/or percentage for categorical variables or mean and standard deviation for continuous variables. Pearson’s Chi-square test and ANOVA tests were performed to identify differences in socio-demographics (age, education level, household income), as well as to identify differences in lifestyle/lifestyle changes between users and non-users of CAM.

Univariable and multivariable logistic regression was used to identify the (sociodemographic) factors independently associated with changes in lifestyle (healthy/unhealthy). Outcomes on changes in lifestyle questions were dichotomized. Change in lifestyle due to corona crisis: answer categories: Yes, I live healthier, Yes, I live unhealthier and No. Multivariable models were derived through several iterations using backward stepwise logistic regression, including all variables that were statistically significant in the univariable analyses. The authors controlled for age, gender and education in these models.

Statistics were carried out using Statistical Package for Social Sciences (SPSS) v. 26.0. Results were statistically significant for p value < 0.05.

A total of 1013 individuals completed the online questionnaire, and, after validation of the data, 1004 respondents (age 18–88 years) were included in the study. As shown in Table 1 , most respondents were between 50 to 69 years of age (37.5%), and female respondents represented 50.7% of the population sample. Respondents were distributed across the 12 provinces, with 27.3% from the northern regions of the Netherlands, 27.6% from the central regions of the Netherlands and 45.1% from the southern regions of the Netherlands. Of all respondents, 46.5% resided in urban zones, 23.8% in sub-urban zones and 24.9% in rural/sub-rural zones. Married respondents living with or without children accounted for the majority of sample distribution, making up to 63.3% of responses followed by individuals living alone without children (24.8%). Half of the respondents (49.9%) had a higher education status and 49.7% of respondents was categorized to have a middle income.

Lifestyle changes during the COVID-19 pandemic

Although the majority of the surveyed population reported no significant change in their daily habits or intake of food/snacks since the COVID-19 outbreak in the Netherlands, we found substantial lifestyle changes in a considerable part of the population, both for the better and the worse (see Table 2 ). 14.0% of all respondents reported a decrease in sleeping hours, while 13.0% reported an increase. One fifth (20.0%) of the respondents reported to snack more than before the COVID-19 pandemic, and 7.7% snacked less. Intake of vegetables increased in 11.7% whereas it decreased in 1.7%.

Table 2 shows that the majority did not know whether their stress levels had changed in relation to ‘the balance between work and childcare’ and ‘care for their family’, respectively 57.8 and 62.1%. 52.3% of the respondents indicated no change in stress related to their own health, but nearly a quarter (22.2%) did perceive more health-related stress or future perspective related stress (27.7%).

As shown in Tables 3 , 80% of the respondents reported that in general they were happy with their current lifestyle. 12.2% of the total population reported an unhealthier lifestyle since the outbreak of the COVID-19 pandemic, whereas 19.3%, ( n = 194) indicated that the COVID-19 pandemic positively influenced their lifestyle (Table 3 ). The 194 respondents reported a healthier lifestyle due to a higher intake of fruit and vegetables (54.6%), exercise (63.4%), and relaxation (46.4%). Only a small proportion of the participants reported to live healthier due to a change in meaning of life aspects/spirituality (6.2%) (Table 3 ).

Remarkably, the number of respondents that thought that lifestyle changes can influence the natural history (symptoms) of COVID-19 once infected, was higher than the number of respondents that thought lifestyle changes can influence the risk of getting infected (Table 3 ). Nearly halve of respondents (48.2%) did not think that a change in their lifestyle could decrease their risk of getting infected by the corona virus (Table 3 ).

Factors independently associated with changes into lifestyle (healthy/unhealthy)

Table 4 shows the univariable statistically significant associated variables with a change to healthy- or unhealthy lifestyle that are entered into the multivariable analyses to come to the final models ( P < 0.05). Based on univariable analyses, no statistically significant associations with a change to a healthy lifestyle were found with regards to age, gender, residential region, smoking, alcohol use, stress in relation to work and stress in relation to future perspectives. With regard to a change to an unhealthy lifestyle no statistically significant associations were found for gender, income level, living region, smoking, alcohol use, use of CAM and anxiety for getting infected their selves with Covid-19.

The final multivariate models (Table 4 ) included 1004/1004 (100%) of the respondents of the survey. Three predictors were strongly associated with changing into a healthy lifestyle: Worried/Anxious getting infected with SARS-coV-2 (OR: 1.56, 95% C.I. 1.26–1.93), CAM use (OR: 2.04, 95% C.I. 1.38–3.02) and stress in relation to financial situation (OR: 1.89, 95% C.I. 1.30–2.74). Together these gave an AUROC of 0.66 (95% CI = 0.63 to 0.71). Similarly, three predictors were strongly associated with changing into an unhealthy lifestyle: Age (OR 18–25: 1.00, OR 25–40: 0.55, 95% C.I. 0.31–0.96, OR 40–55:0.50 95% C.I. 0.28–0.87 OR 55+: 0.1095% C.I. 0.10–0.33), stress in relation to health (OR: 2.52, 95% C.I. 1.64–3.86) and stress in relation to the balance work and home (OR: 1.69, 95% C.I. 1.11–2.57). Together these gave an AUROC of 0.56 (95% C.I. 0.50–0.62)).

Differences in COVID-19-related lifestyle changes between CAM users and non-CAM users

Our multivariable model shows that CAM use is an important predictor of changing to a healthier lifestyle during the first wave of the COVID-19 pandemic and is not statistically significant associated with a change to an unhealthy lifestyle. More than two third (68%) of the respondents indicated use of CAM in the past 3 months. 13.3% of all respondents consulted a CAM practitioner (medical doctor or other (non) healthcare professional specialized in CAM, 59.4% used (CAM) supplements (e.g. vitamins/minerals, herbs, and/or dietary supplements) and 30% indicated to make use of (CAM) self-help techniques ((e.g. breathing exercises, yoga) (Table 5 ).

No statistically significant differences were found between non-CAM and CAM users with regards to mean age, residential region, marital status, education and yearly income. Lifestyle related behaviour measures as smoking, alcohol use and daily exercise were similarly distributed between the two groups. The younger aged (age < 30) and the elderly (age 65+) did make less use of CAM then those aged between 31 and 64 years old, as did men (male non-CAM users: 61.7%).

As shown in Tables 5 , 87.7 and 84.0% of the CAM users and non-CAM users respectively reported that in general they were happy with their current lifestyle. The proportion CAM users that changed into a healthier lifestyle influenced by the COVID-19 pandemic is bigger than the proportion of non-CAM users.

More than one third of the CAM users indicated to think changes in lifestyle could change their risk of getting infected with SARS-coV2 (38.1%), and 46.3% did also think that changing their lifestyle could influence the course of the illness once infected, compared to 40.3% of the non-CAM users and 44.8% of all participants. CAM users were statistically significant less anxious/worried to get infected with COVID-19 than non-CAM users.

In general, CAM users perceived more often an increase in stress than non-CAM users. Rather large differences were found between more stress in the previous three months in relation to work (CAM users: 23.1%, Non-CAM users: 12.3%, P < 0.001), health (CAM users: 25.9%, Non-CAM users: 10.7%, P < 0.001), balance work/childcare (CAM users: 12.0%, Non-CAM users: 7.0%, P = 0.012)), financial situation (CAM users: 21.2%, Non-CAM users:10.7%, P < 0.001)) and future perspective (CAM users: 33.8, Non-CAM users:16.9%, P < 0.001)).

In the 3 months ahead of the survey, CAM users were more aware of their own diet habits than non-CAM users (CAM users: 18.8%, Non-CAM users: 9.1%, P < 0.05).

Intention to continue lifestyle changes and the required support

This study provides information that may be relevant to policy makers, health insurances and research funding organizations to guide future decisions on lifestyle and COVID-19.

Table 6 shows that in general, more than halve of the 194 respondents who reported a positive change in their lifestyle since the start of the COVID-19 pandemic indicated the wish to continue their changes through healthy food (56.2%) and exercise (54.6%). Of the pre-defined options: 1) healthy choices at work/school (food, drinks, exercise during breaks e.g., yoga, tai chi, mindfulness) 2) free choice and reimbursement of any treatment in relation to CAM and Lifestyle; 3) support from GP/Health centre/Community care; 4) online advice and support, and 5) affordable and easilyaccessible healthy food, 55.8% of respondents declared needing none of these.

However, affordable and easily accessible healthy food was perceived as helpful by one third of the respondents (34.7%), followed by healthy choices at work/school and free choice and reimbursement of CAM and lifestyle treatments with respectively 17.2 and 16.0%.

Statistically significant more CAM users reported a desire to continue more activities regarding meaning of life/ spirituality/ (CAM users: 27.4%, Non-CAM users: 10.8%, P = 0.03) in a post Covid-19 era.

This population-based study is a snapshot of the health related lifestyle changes of Dutch residents during the first wave of the COVID-19 pandemic which included nine weeks of Intelligent lockdown as declared by the Dutch Government. Our study seems to indicate that one fifth of the Dutch residents changed their lifestyle into a healthier one and that this was mainly due to healthier food habits, more exercise and more relaxation. More than half of these respondents reported to be motivated to maintain this behaviour change in a post-COVID-19 era. Around 10% of the total study population, on the other hand, admitted to have started living unhealthier due to the corona crisis. 35% of respondents thought that a lifestyle change could change their risk of getting infected by the corona virus and nearly half of the total group thought this change could influence the course of the illness once infected.” Our study also shows that CAM use is an important predictor of changing to a healthier lifestyle during the first wave of the COVID-19 pandemic. The use of CAM and healthy lifestyle has been associated previously [ 15 , 16 , 17 , 18 ], and our results confirm this positive association.

Regardless of the time and context within one decides to eat better, exercise more, or be less stressed, it can be hard to make a lifestyle change, and even harder to make it a habit [ 22 ]. Life changing events might provide a unique opportunity to live healthier and to continue these changes [ 23 ]. Since the outbreak of the novel coronavirus disease (COVID-19) in China, the world is in the grip of a coronavirus pandemic, a unique crisis with disastrous health, societal and economic effects worldwide [ 24 ]. The Corona crisis is said to be the biggest crises since World War III in the Netherlands and is expected to change the way we think and live at individual and societal levels.

A large part of non-communicable diseases is caused by unhealthy behaviour [ 20 , 25 , 26 ]. Addressing modifiable risks such as tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol are among most effective interventions to keep people healthy and productive, reducing the individual, societal and economic impact and suffering caused by non-communicable diseases [ 20 , 25 , 26 ]. Nearly 20% of our respondents indicated that the COVID-19 pandemic positively influenced their lifestyle. This is a positive finding from a public health perspective, in which the importance of a healthier lifestyle to prevent chronic and non-communicable diseases is emphasized. A comparable percentage among a representative sample of the general population of Italy surveyed in the first months of 2020 was found to change to a healthier lifestyle. The survey in Italy further revealed that most of the Italian respondents declared not to have changed its habits (46.1%) (compared to 68% of our respondents), while 37.2% (compared to 12% of our respondents) felt to have made them worse [ 27 ]. This latter difference might be due to the difference in lockdown, with a stricter one in Italy.

Although healthy lifestyles offer a number of health benefits, non- adherence to recommended lifestyle changes remains a frequent and difficult obstacle to realizing these benefits [ 28 , 29 ]. It is therefore promising that of this representative sample of the Dutch population, more than half who changed into a healthier lifestyle indicates to be willing to maintain to these new habits. A US poll has found that as many as 80% of American adults will try to practice self-care more regularly once the COVID-19 pandemic is over [ 30 ]. The prospect of improving health and reducing illness through changes in living habits rather than through curative healthcare, is attractive from the perspective of public health and on economic grounds.

Our final multivariable model for changing into a healthy lifestyle showed positive associations with: (i) anxiety to get infected with SARs-coV-2; (ii) the use of CAM; and (iii) stress with regards to financial situation. Taylor et al. (2020) recently developed the COVID stress Scales (CSS) and identified five factors of stress and anxiety symptoms relating to the coronavirus in two large samples in Canada and the United States including ‘danger and contamination’ and ‘fears about economic consequences’. Two predictive factors (anxiety to get infected with SARs-coV-2 and stress with regards to financial situation) we found to be positively associated with a change into a healthy lifestyle. Previously, Anderson et al. showed that occurrence of life events and subsequent effects, can contribute to health promoted behaviour despite the potential worries, poor health and diseases which may also be associated with them [ 23 ].

Analyses of data from the National Health Interview Study (NHIS) found that CAM users were more likely to use exercise and less likely to be obese than those who did not use CAM [ 15 , 16 ]. Associations of CAM with exercise [ 15 , 16 , 31 , 32 ], higher vegetable intake [ 31 , 32 , 33 ], lower fat or lipid intake [ 31 , 32 , 33 ], and smoking cessation or decreased smoking [ 16 , 31 , 34 ] have been reported previously. These studies, like ours, show a commitment to overall wellbeing that spans both lifestyle and CAM use and hypothesise that CAM therapies may even be used as a gateway to healthy lifestyle. Concurrent use of the two modalities should be investigated further in various populations. Moreover, CAM users in our study indicated to favour support of policy driven decisions related to a healthy lifestyle, consequently, a focus on the Dutch CAM users could work as a gateway to a healthier lifestyle for the general population.

On the other hand, younger age and stress regarding health and the balance between work and family life were found to be positively associated (final multivariable model) with a change into an unhealthy lifestyle. Our data shows that especially younger age was a risk factor for a change into an unhealthier direction. The fact that the young generation seems to be more prone might be due to fact that the restrictions as home confinement during the pandemic has especially impacted their lives by home schooling, working from home and balancing work and childcare (parents) causing a long period of stress resulting into an unhealthier lifestyle. Heightened life stress has been linked to unhealthy eating [ 35 , 36 ] and stressed people are more likely to crave food high in energy, fats, and sugars [ 37 ]. Moreover, parenting is found to be stressful under normative circumstances but pandemic-related data indicate that COVID-19 has led to significant increases in the population’s general stress, a change felt even more acutely for parents than their non-parent counterparts [ 38 ]. The results obtained by our study are relevant if we consider that people with stress in relation to balancing work and family care have a 1.7 higher chance of changing into an unhealthy lifestyle than people not perceiving this specific stress.

Some strengths and limitations of this study need to be noted.

Our study has been strengthened by the fact that the survey was conducted during the first critical period of the epidemic in the Netherlands. Responses from over 1000 individuals were rapidly collected within a period of five days from a representative sample of the population. Another strength is that our sample size was sufficiently large for detecting correlations. A limitation of this study is the rather low response rate of 22% to the survey, increasing the risk of non-response bias. Furthermore, because of the urgency to rapidly assess lifestyle changes in a very critical period of the pandemic, the questionnaire was not first piloted among a smaller sample. Although the research team carefully developed and selected life-style related questions and thoroughly discussed comprehensiveness, flow and clarity of the survey, it is not known whether the questionnaire was fully understandable and acceptable for the target population. Another limitation includes the fact that the results are limited by a self-reported questionnaire. The assessment of lifestyle changes was based on individual recall methods, and not by direct measurement of dietary and sleeping pattern, smoking and alcohol consumption. Respondents may thus have either overestimated or underestimated their changes in behaviour. An obvious other limitation of a cross-sectional study design is that it does not allow causal inferences about relationships and thus limits any claim about the directionality of the results. Last, no data on comorbidities (e.g. diabetes, hypertension and obesity) were gathered for the purpose of this study, which might limit the results. Linking with GP data on comorbidities would strengthen future research [ 15 , 16 , 31 , 32 ].

The COVID-19 pandemic and following Intelligent lockdown provides an unique window of opportunity to improve lifestyle habits on a population level. This is not only important to combat COVID-19 but also the other pandemic; of obesity and other non-communicable lifestyle-related disease. For a part of the Dutch population, the Corona crisis has already brought a shift in thinking, working and lifestyle behaviour, another large part is now motivated to make such changes. From a public health perspective, it is important to use this unique situation optimally and immediately as this increased motivation is crucial to obtain sustainable lifestyle changes, but may disappear quickly once COVID-19 wanes off. Strategies may include investing in prevention and education (e.g. smoking, drugs, alcohol), health campaigns, lowering taxes on healthy foods and sponsorship of sport facilities. Further studies are warranted to see whether this behavioural change is maintained over time, and how (changing) lifestyle behaviour can affect the susceptibility for and the course of COVID-19. Finally, the results of this study are in line with others showing the potential synergistic relationship between CAM use and healthy lifestyle behaviours [ 15 , 16 , 31 , 32 ]. This relation could be targeted in future interventions to increase general wellbeing, symptom control, and clinical outcomes in at-risk populations and might be used as a potential translatable strategy to increase healthy lifestyle behaviours in general populations.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Complementary and Alternative Medicine

Confidence interval

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Acknowledgements

We would like to thank Barbara Wider Vellinga for her assistance with survey development.

This study was funded by co-funding of Triodos Foundation, Fred Foundation, Association of Homeopathy, Iona Foundation and the Artsen Vereniging Integrale Geneeskunde (AVIG)).

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EvdW and MB designed the study. EvdW analysed the data and drafted the manuscript. RH,MB and MJ provided critical feedback for revisions. The authors read and approved the final manuscript.

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van der Werf, E.T., Busch, M., Jong, M.C. et al. Lifestyle changes during the first wave of the COVID-19 pandemic: a cross-sectional survey in the Netherlands. BMC Public Health 21 , 1226 (2021). https://doi.org/10.1186/s12889-021-11264-z

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ORIGINAL RESEARCH article

Impact of covid-19 on lifestyle, personal attitudes, and mental health among korean medical students: network analysis of associated patterns.

$\nJe-Yeon Yun,$

1 Seoul National University Hospital, Seoul, South Korea
2 Yeongeon Student Support Center, Seoul National University College of Medicine, Seoul, South Korea
3 Office of Medical Education, Seoul National University College of Medicine, Seoul, South Korea
4 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea

Introduction

In Republic of Korea, after the exponential increase of COVID-19 confirmed cases comprised of the multiple regional clusters including Daegu and Gyeongbuk area during January and February of 2020 ( 1 ). When this outbreak occurred, the Korean Centers for Disease Control and Prevention (KCDC) instantly dispatched public health doctors to the frontline of pandemic to enable the screening tests on all suspected COVID-19 patients, to conduct quicker quarantine of confirmed-positive patients, and to provide necessary treatment ( 2 ). During this COVID-19 pandemic, the physical and psychological burdens, as well as stresses, have been higher among medical staff members at the forefront of treating patients with COVID-19, compared with the general population ( 3 , 4 ). Medical students are currently experiencing lifestyle changes similar to those of the general public, and are undergoing training as medical professionals, with the aim of preparation for future medical practice ( 5 ). For example, as a response to the sustained COVID-19 pandemic during 2020, medical schools in Republic of Korea also changed every classes to an online format from first-year to fourth-year courses except the clinical clerkship, clinical skills training, and basic laboratory classes such as anatomy lab sessions ( 6 ).

The possible after-effects of the COVID-19 pandemic include a considerably greater incidence of depressive mood and anxiety among college students after the initial pandemic wave ( 7 ). In a recent study, a significant level of psychological distress was observed among medical students in Japan who were subjected to home quarantine restrictions; greater distress was associated with reduced self-esteem and enhanced self-efficacy ( 8 ). In addition, >20% of medical students who had been quarantined in the Hubei Province of China reported moderate or severe levels of depressive mood (23.3%), anxiety (41.9%), and stress (20.9%) ( 9 ). Among medical students in the United Kingdom, considerable proportions have experienced presenteeism (40%) and reported anxiety (37.2%) and depression (46.5%) that affect life satisfaction ( 10 ). Thus, there is a need for timely assessment of interacting patterns among pandemic-related stressors [e.g., potential for transmitting COVID-19 to their families ( 11 ) and living in locations with greater COVID-19 prevalence ( 12 )], lifestyle changes [e.g., online classes ( 13 , 14 ), year of medical school ( 12 , 15 ), perceived social support ( 16 ), and spare time activities and exercise ( 10 )], and mental health factors [e.g., perceived stress, anxiety, depressive mood, history of mental health problems ( 16 ), and availability of psychological care ( 17 )] among college students, who might be more vulnerable to COVID-19-related distress ( 9 ).

Therefore, the current study aimed to examine the interactions among the changed lifestyle (difficulty of online class attendance and use of personal time), cognitive style (perceived threat of infection & proactive coping), mental health (perceived stress, anxiety, and depressive symptoms), and school dropout intention during the COVID-19 pandemic for medical students. In the current study, we hypothesized that the environmental changes during the COVID-19 pandemic would affect the daily routines of medical students in terms of activities such as participation in online classes (rather than on-site lectures in school) and spare time activities (i.e., those influenced by social distancing). Because of the perceived threat of COVID-19 infection, changes in behavioral (social distancing and maintaining personal hygiene) and cognitive (feeling proud of medical personnel at the frontline and a willingness of volunteer) responses were expected. In the context of these ongoing readjustments, the level of life satisfaction might be reduced, thereby leading to a cascade of perceived stress, anxiety, depressive mood, and potential school dropout.

Materials and Methods

Participants and study design.

The current study was conducted for the target population of medical students from the 1st to 4th grade currently enrolled in the Seoul National University College of Medicine (SNUCM) as of June and July of 2020. When students visited the campus and attended the practicum classes or sessions of academic schedule briefing during June or July of 2020, information of the current study was provided. Students with voluntary intension of participating the study could complete anonymous responses for the self-reporting questionnaires distributed in the classroom and submit the anonymous responses upon checking out of the classroom. Exclusion criteria were (1) students who had not been actively enrolled to the SNUCM as of June and July of 2020 or (2) students who did not want to participate the current study. In total, 507 of 597 students (84.9%) responded to the questionnaire. After excluding data for 53 students with missing values, our final dataset included de-identified responses from 454 medical students at Seoul National University College of Medicine during June and July of 2020. The Institutional Review Board at Seoul National University College of Medicine approved the study, and the requirement for written informed consent was waived by the board because this constituted a minimal-risk study protocol (IRB no. 2007-140-1143).

To examine the study hypotheses, the current study used three approaches. First, personal attitudes toward the COVID-19 pandemic, as well as changes in lifestyle and life (dis)satisfaction during the pandemic, were compared among subgroups of students in different years of medical school. Second, directional propagating impacts of the pandemic on the daily lives of medical students were estimated, to derive a group-wise Bayesian network: a model of probabilistic conditional dependencies among the variables of personal attitude toward the COVID-19 pandemic, changes in lifestyle, and changes in life (dis)satisfaction, depicted as a directed acyclic graph. Finally, principal influences on daily life for medical students were deciphered using intra-individual covariance networks, where the edge weights connecting two variables within an individual are proportional to the degrees of (dis)similarities between these variables in terms of the deviation from the group-averaged values of each variable. All procedures were performed in accordance with the ethical standards of the Seoul National University College of Medicine Institutional Review Board concerning human experimentation, as well as the tenets of the Helsinki Declaration of 1975, as revised in 2013.

Difficulty of Online Class Attendance and Use of Personal Time During COVID-19 Pandemic

For more detailed profiling of the impact of COVID-19 on the medical students' daily living, the current study gathered responses concerning difficulties in participating online classes and use of personal time during the COVID-19 pandemic ( Table 1 and Supplementary Material 1 ). First, possible difficulties of attending online classes during the COVID-19 were examined using a question of “If you experienced difficulties due to the online class operation, which of the following did you experience?” Responders were able to choose multiple items among the options of (1) maintaining regular daily routine, (2) insufficient lecturer-students interactions and related difficulties of understanding the study contents, or (3) restricted on-site social activities. For all of these three options separately, responses were binary-transformed into “perceived difficulty” or “difficulty not perceived” prior to further analyses.

Table 1 . Demographic and clinical characteristics: sub-grouped for grade.

Second, pattern of personal time use during the COVID-19 pandemic was measured by way of the single question of “In the last month, which activities did you usually do during private time when you were not involved in school classes or practice?” that allowed multiple choices for a total of six options including sleep, computer game, reading, studying, physical exercise, or spending time with family and friends. Also, for all of these six options separately, responses were binary-transformed into “doing given activity in private time” or “not doing given activity in private time” for further statistical analyses.

Perceived Threat of Infection and Proactive Coping for COVID-19 Pandemic

Seven questions concerning medical students' personal attitudes toward the COVID-19 pandemic were included in the current survey ( Table 1 and Supplementary Material 1 ). First component of “proactive coping for COVID-19 as medical students and to-be medical professionals” was comprised of four items including the (1) compliance for social distancing, (2) taking care of personal hygiene, (3) feelings of pride medical staffs working at frontline, and 4) intention of future volunteering at frontline of epidemic satiations such as COVID-19 as a medical practitioner. Second component that represents “perceived threat of infection” was focused on the (1) students' fear of contracting COVID-19, and their possible roles in the transmission of COVID-19 to (2) family or (3) colleagues. Responses were acquired using a five-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree), and re-coded for between-group comparison ( Table 1 ) and network analyses ( Figures 1 – 3 ).

Figure 1 . A directed acyclic graph of changes in lifestyle, personal attitudes, perceived stress, anxiety, and depressive mood among Korean medical students during the COVID-19 pandemic. The following six most influential items are marked with red circles: (1) personal attitude, fear of infecting my colleagues (R23); (2) perceived stress, feeling nervous and stressed (R43); (3) perceived stress: feeling “being on top of things” (R48); (4) anxiety, trouble relaxing (R54); (5) depressive mood, feelings of failure or that I have let myself/family members down (R67); and (6) depressive mood, trouble concentrating on things such as reading the newspaper or watching television (R68). [Personal attitude for COVID-19 pandemic] 21R = fear of my getting COVID-19; 22R = fear of my transmitting COVID-19 to family; 23R = fear of my transmitting COVID-19 to colleague; 24R = my keeping social distance; 25R = my keeping personal hygiene; 26R = feeling proud for medical staff at frontline; 27R = my willing to future volunteer at frontline/3R = intension of school dropout within recent 3 months; grade = grade as medical student/[Perceived stress] 41R = upset; 42R = unable to control; 43R = nervous or stressed; 46R = cannot cope with many things have to be done; 49R = angered for things outside of one's control; 410R = felt difficulties piled up could not be overcome; 44R = confidence for personal problems; 45R = things going one's way; 47R = control irritation; 48R = on the top of things/[Anxiety] 51R = nervous or anxious; 52R = cannot stop control worrying; 53R = worrying too much for different things; 54R = trouble relaxing; 55R = restless; 56R = easily annoyed or irritable; 57R = afraid of awful things happen/ [Depressive mood] 61R = feeling down, depressed, or hopeless; 62R = little interest or pleasure in doing things; 63R = trouble falling asleep or staying too much sleep; 64R = poor appetite or overeating; 65R = psychomotor change; 66R = tired or little energy; 67R = feel bad about oneself; 68R = trouble concentrating; 69R = idea of suicide or harming oneself/[Spare time activities in COVID-19 pandemic] 91R = sleep; 92R = computer game; 93R = reading; 94R = study; 95R = exercise; 96R = spend time with family and friends; /[Difficulties of participating in online classes in COVID-19 pandemic] 101R = maintaining regular daily routine; 102R = insufficient interaction for understanding; 103R = restriction of on-site social activities.

Figure 2 . Rank-transformed betweenness centrality calculated from the intra-individual covariance networks of changes in lifestyle, personal attitudes, perceived stress, anxiety, and depressive mood among Korean medical students during the COVID-19 pandemic. In the x-axis of the violin plot (lower), the following six most influential items (hubs; top 12% for the rank-transformed betweenness centrality in ≥25% of participants ( n = 454) at a network sparsity level of K = 0.14) are written in red: (1) personal attitude, fear of infecting my colleagues (R23); (2) perceived stress, feeling nervous and stressed (R43); (3) perceived stress: feeling “being on top of things” (R48); (4) anxiety, trouble relaxing (R54); (5) depressive mood, feelings of failure or that I have let myself/family members down (R67); and (6) depressive mood, trouble concentrating on things (R68). Items that showed significant relationships with recent intentions to drop out of school, perceived stress, or depressive mood are written in blue.

Figure 3 . Significant correlations between the intensity of perceived stress or depressive mood vs. rank-transformed betweenness centralities of personal attitudes or changes in lifestyle during the COVID-19 pandemic among Korean medical students ( n = 454; statistical threshold of |Spearman's rho| > 0.3 and P < 0.001). Values of rank-transformed betweenness centrality were calculated from the intra-individual covariance networks (at network sparsity level of K = 0.14) containing the changes in lifestyle, personal attitudes, perceived stress, anxiety, and depressive mood. (A) Correlations between the total score of perceived stress scale (PSS) vs. rank-transformed betweenness centrality values of “personal attitude, fear of infecting my family members” (Spearman's rho = −0.354, P < 0.001). (B) Correlations between PHQ-9 (depressive mood) total score vs. rank-transformed betweenness centrality values of “engaging in computer games in spare time” (Spearman's rho = 0.304, P < 0.001).

A principal components analysis (PCA) was conducted on the seven items with orthogonal rotation (varimax). The Kaiser-Meyer-Olkin measure verified the sampling adequacy for the analysis KMO = 0.713 (fair), and all KMO values for individual items were ≥0.5, which is above the acceptable limit. Barlett's test of sphericity, χ 2 (21) = 1,235.02, P < 0.001, indicating that correlations between items were sufficiently large for PCA. An initial analysis was run to obtain eigenvalues for each component in the data. A total of two components had eigenvalues over Kaiser's criterion of 1 and in combination explained 68.13% of the variance. These two components of “proactive coping” and “fear of infection” had higher reliabilities as reflected in the values of Cronbach's α = 0.762 and 0.865, respectively.

Mental Health: Perceived Stress, Anxiety, and Depressive Symptoms

First, perceived stress during the most recent 1 month was measured using the Perceived Stress Scale (PSS) ( 18 ) validated for Korean ( 19 ). Response for the items of PSS were retrieved using the 5-point Likert scale. In the current study, value of Cronbach's α for the PSS was 0.859. Second, anxiety during the most recent 2 weeks was evaluated using the Generalized Anxiety Disorder-7 (GAD-7) ( 20 ) validated for Korean ( 21 ). Third, depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) ( 22 , 23 ) validated for Korean ( 24 ). Responses to each question in the GAD-7 and PHQ-9 were acquired using a four-point Likert scale. Cut-off scores of moderate depressive mood and moderate anxiety applied in the current study were PHQ-9 total score ≥10 and GAD-7 total score ≥10, respectively, as found in validation studies for Korean population ( 21 , 24 , 25 ). In the current study, Cronbach's α values of 0.922 and 0.859 demonstrated higher reliabilities of GAD-7 and PHQ-9, respectively.

School Dropout Intention During the COVID-19 Pandemic

School dropout intention ( 26 – 28 ) during the COVID-19 pandemic was asked by way of the single question of “Have you ever considered quitting your studies in the past 3 months (=since the start of current semester (March of 2020) as of June 2020)?” Responders could choose either “yes” or “no.”

Network Analysis: Directed Acyclic Graph

The directional propagation of the COVID-19 pandemic in medical students' daily lives, observed by means of 43 variables, were estimated as a Bayesian network using the R package named Bnlearn ( https://www.bnlearn.com/ ). The 43 variables included personal attitude toward COVID-19 (seven variables of item 02), school dropout intention in the most recent 3 months (item 03), spare time activities during the COVID-19 pandemic (six variables of item 09), difficulties participating in online classes during the COVID-19 pandemic (three variables of item 10), perceived stress (10 variables of item 04; PSS), anxiety (seven variables of item 05; GAD-7), and depressive mood (nine variables of item 06; PHQ-9).

First, an optimal network structure for a bootstrapped sample [from the original dataset ( n = 454)] was estimated using a score-based heuristic local search method, known as the hill-climbing algorithm ( 29 , 30 ). After the global probability distribution (=factorization of the joint probability distribution) of the network had been determined, the parameters of local probability distributions for each node (conditional on the learned network structure) were estimated. Second, a subset of edges crucial for explaining the given sample were selected based on their higher goodness-of-fit score (e.g., Bayesian Information Criterion) ( 29 , 30 ). These procedures were repeated 10,000 times, and the most consistent network edges in terms of presence and directionality were selected for the final averaged version of the directed acyclic graph. The directed acyclic graph defined probabilistic dependencies (directional edges) based on the Markov property of Bayesian networks (=direct dependence of each node only on their parental nodes) among the variables (nodes) ( Figure 1 ) ( 30 ).

Network Analysis: Intra-Individual Covariance Network and Graph Theory Approach

Intra-individual covariance depicts inter-item similarities and differences within each individual to determine the variance from the group-averaged value of each item. In the current study, intra-individual covariance between two different items was defined using the following formula: 1 e ( ( x A - M A ) S D A - ( x B - M B ) S D B ) 2 . Thus, the intra-individual covariance value could be distributed between 0 and 1, where higher values indicate greater similarity in degrees of variance [= differences between raw values (X A and X B ) and group-averaged values (M A and M B , n = 454) divided by the group-level standard deviation of each item (SD A and SD B , n = 454)] between the two items of A and B within an individual ( 31 , 32 ). By calculating these intra-individual covariance values among the 43 variables described above within each individual, intra-individual covariance networks were constructed for each individual ( n = 454).

To uncover the principal influences on medical students' daily lives during the COVID-19 pandemic among these 43 variables, the current study applied the graph theory approach to these intra-individual covariance networks. First, network connectedness, small-worldness (σ, degree of balance between the overall network integration vs. network segregation into distinctive subgroups), and modularity (Q, heuristically estimated degree for a network to be subdivided into clearly delineated and non-overlapping subgroups) were derived using the network density range of K = 0.05–0.20 (with intervals of 0.1; when K = 0.05, only the top 5% largest values of intra-individual covariance survived as edges comprising an intra-individual covariance network). Second, a local network metric, known as betweenness centrality values (variable with higher betweenness centrality might be a “shortcut” among a larger number of variables that showed similar degrees of variance from group-averages within an individual), was estimated at the most sparse level of network density (K) that satisfies (1) network connectedness (>80% of items connected to each other, because they have similar degrees of variance from the group-averaged values of each variable), (2) small-world organization (σ > 1), and (3) modularity (Q > 0.3) for > 95% of participants ( n = 454). These values were rank-transformed within each individual. All graph theory processing was conducted using the Brain Connectivity Toolbox ( 33 ).

Statistical Analyses

According to the year of medical school, between-group comparisons of sex, school dropout intention in the most recent 3 months, spare time activities, and difficulties in online class participation were conducted using the chi-squared test of homogeneity. Concerning personal attitudes toward the COVID-19 pandemic, the Kruskal–Wallis test was applied. Total scores of PSS, GAD-7, and PHQ-9 were compared between groups using one-way analysis of variance (ANOVA). Thresholds of statistical significance were set at P < 0.05/3 (=number of domains including personal attitudes, changed lifestyle, and life (dis)satisfaction) = 0.017 (for main analyses) and P < 0.05/6 (=number of between-group comparisons) = 0.008 (for post-hoc analyses), respectively.

Demographic and Clinical Characteristics

In total, 507 of 597 students (84.9%), higher percentage of response than other recent studies for medical students ( 34 ) or public health doctors ( 35 ) during COVID-19 pandemic, responded to the questionnaire. After excluding data for 53 students with missing values, our final dataset included de-identified responses from 454 medical students (123 in the first year of medical school, 110 in the second year, 121 in the third year, and 100 in the fourth year) at Seoul National University College of Medicine during June and July of 2020. Participant ages ranged from 20 to 33 years (mean age, 19.1 ± 9.0 years), and participants included 289 men (63.7%) and 165 women (36.3%). Table 1 describes between-group comparisons of (1) personal attitude toward the pandemic; (2) difficulties in online class participation during the pandemic, as well as spare time activities; (3) intensity of perceived stress-anxiety-depressive mood and school dropout intention in the most recent 3 months. Regarding personal attitudes toward the pandemic, stronger fear of contracting COVID-19 and transferring the infection to their family members or colleagues were reported by fourth-year medical students (slightly worried), compared with other medical students (not very worried; all P < 0.008). In addition, the first-year medical students felt greater pride for medical staff members working at the COVID-19 frontline, compared with third- or fourth-year medical students, and maintained better social distancing, compared with third-year medical students (all P < 0.008).

Conversely, the percentage of respondents who reported difficulty in the maintenance of a regular daily routine was higher among first-year medical students (32.5%)—who had been enrolled in online classes—than among third-year medical students (17.4%)—who were engaged in on-site hospital training. During their spare time, first-year medical students were more likely to study (65.9%) and less likely to exercise (21.1%), compared with medical students at other points in the program (41.7% for study and 40.0% for exercise). Furthermore, the mean intensity of perceived stress (total score of PSS) and depressive mood (total score of PHQ-9) were higher among first-year medical students (21.0 ± 7.6 for perceived stress and 5.7 ± 4.6 for depressive mood) than among third-year medical students (for perceived stress) and fourth-year medical students (for both perceived stress and depressive mood; all P < 0.008). Furthermore, moderate depressive mood (PHQ-9 total score ≥ 10) or anxiety (GAD-7 total score ≥ 10) were found in 11.9% ( n = 54) or 18.5% ( n = 84) of the participants, respectively. Finally, school dropout intention in the most recent 3 months ( P < 0.001 for main analysis) was higher in first- and second-year medical students (49.8%) than in third- and fourth-year medical students (21.3%).

Propagated Impacts of COVID-19 in Daily Lives of Medical Students: Directed Acyclic Graph

Using item-level responses for the whole dataset ( n = 454), a group-wise directed acyclic graph was established to uncover the propagating patterns among the following items: (1) personal attitude toward pandemic; (2) changes in lifestyle (difficulties in online class participation during the pandemic and spare time activities during the pandemic); and (3) changes in life (dis)satisfaction (perceived stress, anxiety, depressive mood, and school dropout intention in the most recent 3 months). As shown in Figure 1 , the results indicated that medical students' distress during the COVID-19 pandemic was initiated by the perception of unexpected events related to pandemic (41R). Moreover, it extended to the fear of transferring COVID-19 to colleagues (23R), perceived stress [nervous and stressed feelings (43R) and feeling a loss of situational control (48R)], anxiety [trouble relaxing (54R)] and depressive mood [feelings of failure (67R) and trouble concentrating (68R); all items listed above are marked as red circles in Figure 1 ].

Principal Influences on Medical Students' Daily Lives During the COVID-19 Pandemic: Graph Theory Approach for the Intra-Individual Covariance Network

The principal influences on personal attitudes, changes in lifestyle, and changes in life (dis)satisfaction during the COVID-19 pandemic were identified using rank-transformed betweenness centrality values ( Figure 2 ), estimated from the intra-individual covariance networks (containing items also in the directed acyclic network; Figure 1 ) at the sparsity level of K = 0.14 (in which the top 14% of edges with higher covariance values survived) that satisfied the following criteria for > 95% of participants ( n = 454): (1) network connectedness (>80% of items connected to each other), (2) small-worldness (sigma > 1), and (3) modularity (Q > 0.3).

Accordingly, the following six items were ranked as top 10% items (=rank-transformed betweenness centrality ≤ 4) for more than 40% of participants: (1) fear of transferring COVID-19 to colleagues (23R; personal attitude), (2) nervous and stressed feelings (43R; perceived stress), (3) feeling a loss of situational control (48R; perceived stress), (4) trouble relaxing (54R; anxiety), feelings of failure (67R; depressive mood), and trouble concentrating (68R; depressive mood). These items were selected as principal influences (marked with red-rimmed circles in Figure 1 ; names written in red color at the bottom of Figure 2 ).

Differential Patterns of Connectedness According to Life (dis) Satisfaction During the COVID-19 Pandemic

Correlation analyses between the severity of perceived stress (total score of PSS), anxiety (total score of GAD-7), and depressive mood (total score of PHQ-9) vs. rank-transformed centrality derived from the intra-individual covariance networks uncovered associations between higher rank of betweenness centrality for the “fear of transmitting COVID-19 to family members (22R)” and higher perceived stress (Spearman's rho = −0.354, P < 0.001; Figure 3A ). In contrast, a higher rank of betweenness centrality for “engaging in computer games in spare time (92R)” was associated with lower depressive mood (Spearman's rho = 0.304, P < 0.001; Figure 3B ).

Study Summary

To our knowledge, this study is the first to decipher the influencing cascade of changed lifestyle (difficulty of online class attendance and use of personal time), cognitive style (perceived threat of infection & proactive coping), mental health (perceived stress, anxiety, and depressive symptoms), and school dropout intention during the COVID-19 pandemic for medical students, by means of network-based approaches. For reducing the possible transmission of COVID-19 by way of on-site interpersonal interactions, medical schools in Republic of Korea also changed most of the classes to an online format from first-year to fourth-year courses ( 6 ). For basic laboratory classes such as anatomy lab sessions, students were equipped with personal protective equipment students and were divided into smaller groups to reduce the spread of possible infections ( 6 ). After the partial loosening of social distancing as of May of 2020 by announcement of government, core clinical clerkship programs were re-opened at training hospitals and conducted in compliance with preventive guideline for COVID-19 pandemic ( 6 ).

In the current study, depressive mood, anxiety, and intention of school dropout were observed in 11.9, 18.5, and 38.3% of medical students, respectively. These tendencies were more prominent among junior medical students. The current results are not higher than the prevalence of clinically relevant depressive symptoms measured during the pre-pandemic era for medical students worldwide (27–28%) ( 36 , 37 ) and in South Korea (10.9–23%) ( 38 – 40 ), who had already been reporting higher levels of depressive mood, anxiety, and psychological distress, compared with the general population ( 41 ). However, because the profile of psychological responses to stressful situations can vary among individuals, network analyses were conducted to uncover the possible directional cascade of psychological symptom progression and core influencing components. A directed acyclic graph began from the perception of unexpected events; then transitioned to nervous and stressed feelings, trouble relaxing, and feelings of failure; and finally progressed to trouble concentrating, feeling a loss of situational control, and fear of infecting colleagues. These six features were also highly ranked for betweenness centrality in the intra-individual covariance networks. Of note, perceived stress showed a negative association with rank-transformed betweenness centrality of “fear of infecting my family members (Spearman's rho = −0.354)”; in contrast, a higher rank of “engaging in computer games in spare time” for betweenness centrality was associated with lower depressive mood (PHQ-9 total score; Spearman's rho = 0.304) (all P < 0.001).

Influencing Patterns Among Perceived Stress, Personal Attitudes, and Changes in Lifestyle

In the current study, perceived stress in response to the COVID-19 pandemic began from the surprise concerning the unexpected occurrence of the COVID-19 pandemic. After this feeling of surprise transitioned into nervousness and distress, medical students experienced feelings of anxiety (“on edge”), irritability, and fatigue. When medical students who had been using spare time for sleeping felt that they were unable to control the important things in their lives, they experienced difficulty in maintaining a regular daily routine during social distancing. This is consistent with other studies, which showed that college students during the COVID-19 pandemic experienced distress when adjusting to new academic activities and changes in sleeping pattern. Their social isolation and “all-or-none” cognitive style could lead to worsened mental health and life satisfaction ( 42 , 43 ). Furthermore, when they had not been able to cope with all the tasks they had to complete and felt that difficulties were becoming so extensive that they could not be managed, medical students with little interest or pleasure in doing things sometimes considered taking a leave of absence from school. Timely provision of academic mentoring and networking, as well as psychological care for possible depressive moods, might be crucial in minimizing unintended leaves of absence from school by medical students during the COVID-19 pandemic ( 44 – 47 ).

In contrast, the level of confidence that they are in control of a situation and aware of changes, and whether they used spare time for computer games, might influence the use of spare time to read books. Notably, reading books has been widely used to aid in coping with sustained adaptation distress among veterans ( 48 ), burnout among oncologists ( 49 ), and physical illnesses [e.g., hemodialysis ( 50 )]. Furthermore, medical students who have been angered because of things outside of their control, but also felt pride in seeing medical staff members at the COVID-19 frontline, reported a willingness to volunteer to work as a medical professional at the frontline of future epidemic situations. As a possible proactive coping mechanism, some of them volunteered as peer-tutors ( 51 ).

Influencing Patterns Among Anxiety, Personal Attitudes, and Changes in Lifestyle

To control the amplification of anxiety among medical students during the COVID-19 pandemic, capacities for voluntary relaxation and maintenance of social ties with family and friends might be helpful. The current study showed that ~18.5% of medical students reported anxiety (GAD-7 total score ≥ 10). Because they already feel distress and experience hopelessness about the increasing difficulties, initial anxiety that involves feeling nervous, anxious, or on edge might escalate. Thus, the students may be unable to stop or control worrying about various things. Because sustained worrying could lead to trouble relaxing and subsequent fear of an awful outcome, preemptive application of progressive muscle relaxation ( 52 ) or the therapeutic use of a coloring book ( 53 ) might be suggested.

Importantly, medical students who had a fear of transmitting COVID-19 to family members and a fear of an awful outcome used their spare time to see family and friends. Of note, the severity of perceived stress (= total score of PSS) was higher in medical students for whom the transformed z-score value [using the means and standard deviations of given items calculated from all participants ( n = 454)] of fear for transmitting COVID-19 to family members was similar to most other personal attitude-changed lifestyle-life (dis)satisfaction items (i.e., higher-ranked values of betweenness centrality derived from the intra-individual covariance network; Spearman's rho = −0.354, P < 0.001). Because a weak sense of coherence is associated with greater risks of mood disturbance and anxiety during the COVID-19 pandemic ( 54 ), medical staff members at the COVID-19 frontline also require familial support and social connectedness to mitigate the fear of infection ( 55 ).

Influencing Patterns Among Depressive Mood, Personal Attitudes, and Changes in Lifestyle

Lowered self-efficacy could be a principal influence on the progression of depressive symptoms and distress. In the current study, ~11.9% of medical students reported a depressive mood (PHQ-9 total score ≥ 10). Sustained surprise and uncontrollable worrying during the COVID-19 pandemic could result in feeling “down,” depressed, or hopeless. Furthermore, if medical students do not experience much interest or pleasure in their tasks and instead exhibit fear of an awful outcome, they might regard themselves as failures and have reduced self-confidence in handling personal problems. As symptoms of depressive mood and anxiety worsen, medical students complain of concentration difficulty. Altered confidence in handling personal problems would be followed by changes in capacity for controlling irritation, life contentment, and feelings of situational control and awareness of changes. To prevent the worsening of depressive moods among medical students during the COVID-19 pandemic, there is a need for balancing of a negative cognitive style and collective evaluation tendencies by means of Socratic questioning and more objective evaluations of tasks based on actual evidence ( 56 , 57 ).

Limitations

This study had some limitations. First, the current study is cross-sectional, and therefore, comparisons with pre-pandemic period per study participant were not possible. Recent studies showed an increased prevalence of psychiatric symptoms such as distress, anxiety, insomnia, and depressive mood during the COVID-19 pandemic, compared with pre-pandemic assessments ( 58 ). Throughout follow-up studies during this pandemic, the prevalence of symptoms was stable ( 59 ) or decreasing ( 60 , 61 ), compared with earlier stages. Further longitudinal cohort studies ( 62 , 63 ) are needed to understand the long-term after-effects of the COVID-19 pandemic on the interacting pattern among personal attitudes, changes in lifestyle, and changes in life (dis)satisfaction. Second, three items used in the current study in measurements of “difficulty of online class attendance (1 item) & use of personal time (1 item) during COVID-19 pandemic” and “school dropout intention during the COVID-19 pandemic (1 item)” were not validated in the current study. Third, the current study did not explore the possible mediation effect of socioeconomic status between the COVID-19 pandemic and its impact on medical students. Specifically, people with lower socioeconomic backgrounds could find difficulties in adjusting themselves among the changing situation of COVID-19 ( 64 ). Fourth, the directed acyclic graph applied in the current study was based on probabilistic and causal modeling, and did not consider the possibility of bidirectional interactions among variables. Future studies might be suitable for exploring such bidirectional interactions by applying newly proposed tools [e.g., interaction directed acyclic graph ( 65 )] that have been sufficiently verified.

Conclusions

Overall, the current study examined the influencing cascade of changes in lifestyle, personal attitudes, and life (dis)satisfaction among medical students during the COVID-19 pandemic using network-based approaches. To minimize distress propagation, timely control is necessary concerning the following principal influences: nervous and stressed feelings, trouble relaxing, feelings of failure, trouble concentrating, fear of infecting colleagues, and feeling a loss of situational control.

Data Availability Statement

The datasets used in the current study are available from the corresponding author (Sun Jung Myung, issac73@snu.ac .kr) on reasonable request.

Ethics Statement

The studies involving human participants were reviewed and approved by the Institutional Review Board at Seoul National University College of Medicine approved the study protocol, and the requirement for written informed consent was waived by the board because this constituted a minimal-risk study. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

J-YY, JK, SMy, HY, SMo, HR, and J-JY conceived and designed the study idea. J-YY and MJ managed literature searches and wrote the manuscript. J-YY, JK, SMy, HY, SMo, HR, and J-JY critically reviewed the manuscript. All authors contributed to and have approved the final manuscript.

This research was funded by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2017R1D1A1B03028464). The funder (Korean Association of Public Health Doctors) had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflict of Interest

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

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.702092/full#supplementary-material

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Keywords: COVID-19, medical students, mental health, directed acyclic graph, intra-individual covariance network, lifestyle changes, fear of infection

Citation: Yun J-Y, Kim JW, Myung SJ, Yoon HB, Moon SH, Ryu H and Yim J-J (2021) Impact of COVID-19 on Lifestyle, Personal Attitudes, and Mental Health Among Korean Medical Students: Network Analysis of Associated Patterns. Front. Psychiatry 12:702092. doi: 10.3389/fpsyt.2021.702092

Received: 29 April 2021; Accepted: 16 July 2021; Published: 18 August 2021.

Reviewed by:

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

*Correspondence: Sun Jung Myung, issac73@snu.ac.kr

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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‘When Normal Life Stopped’: College Essays Reflect a Turbulent Year

This year’s admissions essays became a platform for high school seniors to reflect on the pandemic, race and loss.

By Anemona Hartocollis

This year perhaps more than ever before, the college essay has served as a canvas for high school seniors to reflect on a turbulent and, for many, sorrowful year. It has been a psychiatrist’s couch, a road map to a more hopeful future, a chance to pour out intimate feelings about loneliness and injustice.

In response to a request from The New York Times, more than 900 seniors submitted the personal essays they wrote for their college applications. Reading them is like a trip through two of the biggest news events of recent decades: the devastation wrought by the coronavirus, and the rise of a new civil rights movement.

In the wake of the high-profile deaths of Black people like George Floyd and Breonna Taylor at the hands of police officers, students shared how they had wrestled with racism in their own lives. Many dipped their feet into the politics of protest, finding themselves strengthened by their activism, yet sometimes conflicted.

And in the midst of the most far-reaching pandemic in a century, they described the isolation and loss that have pervaded every aspect of their lives since schools suddenly shut down a year ago. They sought to articulate how they have managed while cut off from friends and activities they had cultivated for years.

To some degree, the students were responding to prompts on the applications, with their essays taking on even more weight in a year when many colleges waived standardized test scores and when extracurricular activities were wiped out.

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Two Years In: How the Pandemic Changed Our Lives

From remote work to major life developments, the COVID-19 era left its mark on Duke staff and faculty

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Two years ago this week, the novel coronavirus fully took hold in the United States. While it had been in the country earlier, the second week of March 2020 was when cases spiked, and soon after, Duke University President Vincent E. Price announced in an “urgent message” that faculty and staff who could work from home should do so.

Masking and social distancing policies became the norm while businesses, schools and offices went quiet.

As some safety measures ease , COVID-19 has infected nearly 80 million Americans and left nearly 970,000 dead. As the pandemic raged with variants, education, research and health care continued across Duke University and Duke University Health System at a high level.

And many of us are forever changed.

“I think we, as a people, are different,” said Duke Associate Professor of Medicine Jon Bae, a co-convener for the mental and emotional well-being portion of Healthy Duke. “In the last two years, people have learned different ways of working, different ways of living and different ways to take appreciation for things.”

Jon Boylan is one of those.

Jon Boylan welcomed his daughter Elora during the pandemic. Photo courtesy of Jon Boylan.

The past two years have drawn Boylan closer to his wife, Katie, a steadying influence during uncertain times. But starting a family against the backdrop of a global pandemic has given him a deeper respect for how forces outside of our control can alter plans.

“I wasn’t one of those people who had time to learn how to bake bread or anything,” Boylan said. “But I think in terms of personal growth, a lot happened.”

We caught up with some Duke colleagues to hear how their lives are different two years into the pandemic.

Committing to Self-Care

Melanie Thomas turned preparing for a hiking trip to Spain into a self-care routine. Photo courtesy of Melanie Thomas.

“For me, I thought, ‘How do I have a rich, full life amid all of this and keep a positive attitude?’” Thomas said.

She decided that she needed a goal that she could work toward until the world opened up. Already with a long list of outdoors adventures under her belt, Thomas decided to plan a summer 2021 trip to Nepal to hike the summit of the 21,247-foot Mera Peak.

For the next several months, Thomas began running, working out at a socially distanced gym, and incorporating as many walks as possible into her day. While the trip to Nepal was the goal, the exercise to prepare for it became a central piece of her self-care routine.

“I just love being outside, it’s very restorative,” Thomas said. “And I like physical challenges, I get the rush of endorphins from that. So putting those two things together just helps me out mentally. Even just a short walk can help me focus.”

Eventually, travel complications required Thomas to postpone the trip to Nepal. Instead, she flew to Spain and, over three weeks in September and October of 2021, she hiked 335 miles on the Camino de Santiago pilgrim trail.

“It was basically like a walking meditation for three weeks,” said Thomas, who is now exercising with an eye toward a 2023 Nepal trip. “It’s really an incredible experience.”

Defining Your Purpose

Johanna Casey found purpose in the challenge of caring for COVID-19 patients. Photo courtesy of Johanna Casey.

But she said COVID-19 tested everyone’s resolve.

“You just don’t know how you’re going to react to something until you’re in it,” Casey said.

In March 2020, Casey was the clinical team lead for Duke Raleigh’s ICU, a managerial role with less hands-on patient care. But it wasn’t far into the pandemic before Casey’s desire to help patients led her to return to a clinical nurse role.

There, she saw the virus’ danger up close. At one point in the summer of 2020, 13 of the 15 beds in the ICU were occupied by COVID-19 patients on ventilators. With no visitors allowed for COVID-19 patients, Casey witnessed several wrenching goodbyes said over cellphone.

Her challenges didn’t end when she left work. With four children and a husband who’s a police officer in Durham, at home, Casey faced stress from home schooling and a spouse also on COVID-19’s front lines.

While many ICU nurses ask to be transferred to different units due to the emotional strain, Casey was inspired by seeing colleagues bravely push forward, giving comfort and dignity to patients facing dire situations. She also said that, as the pandemic wore on, the bond between ICU nurses grew stronger.

As hard as these past two years have been, Casey, who still serves in the ICU and recently began working toward an Acute Care Nurse Practitioner certificate through the Duke University School of Nursing , said the pandemic experience has only deepened her connection to her work.

“We all faced this as a challenge, personally, emotionally and professionally, and hopefully learned to grow through it and be better if this ever happens again,” Casey said.

Taking Charge of Physical Health

While working remotely, John Carbuccia was able to fit in more walks. Photo courtesy of John Carbuccia.

After the pandemic required many Duke staff and faculty members to work remotely , sending Carbuccia from working in the bustling Smith Warehouse to his Mebane home, the IT Analyst with Duke’s Office of Information Technology found himself making healthier choices without even thinking.

Instead of eating lunch out or grabbing meals from events in his on-campus workspace, Carbuccia found himself eating homemade breakfasts, lunches and dinners. Scrambled eggs with vegetables, or simply prepared salmon filets are some of current favorites.

And without a commute, he has time for walks around his neighborhood before and after work.

Carbuccia saw the result of these changes a few months into the pandemic when he stepped on the scale and saw that he’d lost 26 pounds.

“When I stepped on the scale, I said, ‘Holy Moses! I lost a lot of weight, and I wasn’t even planning to!’” Carbuccia said.

A Better Mental Space

Erica Herrera found herself more at ease working from home. Photo courtesy of Erica Herrera.

And each day also involved a roughly 30-minute commute along I-85 to her home in Graham, where the heavy traffic made her feel especially anxious, leaving her tense when she arrived at work or home.

But the past two years saw her work go fully remote, and now a move to a hybrid arrangement featuring one day of on-site each week. She cherishes the time she can spend working from home, often with her two dogs – Marx, a Boston Terrier, and Duke, a rescue – lounging at her feet.

“Working at home, I feel like my mental health is in a better place,” said Herrera, a wife and mother of three.

Herrera isn’t alone in her appreciation of remote work. According to a Pew Research Center report from February 2022, approximately six in 10 workers who can do their jobs from home are working remotely most or all of the time.

Herrera said her hybrid schedule leaves her feeling mentally fresh when she begins her workday and better able to transition between work and personal life.

“I’m happier,” Herrera said. “I’m more at ease.”

Learning on the Fly

LaKanya Roberts has been impressed with her team's productivity while working remotely. Photo courtesy of LaKanya Roberts.

“Even though some of us had experience working remotely, it was still new,” said Roberts, who’s worked at Duke for nearly a decade. “Regardless of how much experience you had, I don’t think we were mentally or technologically ready for that quick of a transition.”

Roberts recalls PRMO leaders moving quickly to get desktops, monitors, laptops, cameras and headsets in the hands of team members. She also recalls many of her colleagues working diligently to familiarize themselves with new tools and programs, such as the collaboration platform Jabber, that were different from what was used in the PRMO offices on South Alston Avenue in Durham.

Roberts and her colleagues also had to learn how to collaborate with one another when communication came by email and chat messages instead of a quick face-to-face conversation.

Working each day from her home in Franklinton, Roberts continues to help Duke Health patients with billing concerns. She’s part of a large team that gelled amid the pandemic and kept the pace of customer support high.

With PRMO keeping colleagues connected with department meetings and team-building Zoom events, Roberts said these past two years have given her a new appreciation of the resilience of her colleagues.

“It made me proud because nobody skipped a beat,” Roberts said. “Everybody took accountability. While some of our thinking and the logic behind how we normally do things had to change, I’m proud that it was still a really seamless transition for us.”

Finding Flexibility

Mary Atkinson, right, and her son, West, left, have been able to spend quality time together. Photo courtesy of Mary Atkinson.

“This is something that would have never happened before the pandemic,” said Atkinson, a regulatory coordinator with the Duke Department of Surgery .

Like many administrators in Duke’s research areas, Atkinson has been working fully remote since the pandemic began, trading in her fourth-floor workspace in Erwin Terrace for a spot at home. The change reshaped Atkinson’s day-to-day routine in a drastic way, ridding her of a commute that ate up two hours each day.

Now, with more time to spend with her son, West, born before the pandemic, and her 10-month-old daughter, Iris, Atkinson, who has worked for Duke for nearly seven years, has the flexibility that allows her to feel rooted. And with more balance, she hopes to let the roots of her family, as well as the cucumbers, tomatoes and peppers that will be in the ground soon, grow strong.

“I’ve attempted a very small garden each year, but we have a very shady lot,” Atkinson said. “But this year, we’re putting it in the front, where we get a lot of sun, and West is helping me, so it’s going to work.”

A World of Change

Rachel Meyer started a family, getting married and welcoming her daughter Maggie, during the pandemic. Photo courtesy of Rachel Meyer.

In late 2019, she met Neil Gallagher at a party and hit it off. The pair dated for the next few months and, when the pandemic forced everyone to limit contact with others, they decided to keep each other in their quarantine bubble.

“It was one of those easy connections where we were really comfortable with each other,” said Meyer, who shared the story of her mental health journey with Working@Duke just before the coronavirus outbreak.

Over the next several months, the pair grew closer and, by the end of 2020, they’d begun talking about getting engaged and starting a family. Those plans hit warp speed when they found out Meyer was pregnant in early 2021. Not long after, they were engaged and later married in a small ceremony in Raleigh in July of last year.

And over a few hectic days in early October, the pair closed on a house together in Raleigh and Meyer gave birth to a healthy baby girl named Maggie.

Now in a very different spot in life from where she was when the pandemic began, Meyer said she greets each day with a new feeling of purpose and strong sense of gratitude.

“I think my husband and I have been keenly aware of how odd it’s been and how many blessing we’ve had at a time when life has been really hard for a lot of people,” Meyer said.

How has the pandemic changed your life? Send us your story and photographs through our story idea form or write [email protected] .

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Open Access

Peer-reviewed

Research Article

Impact of COVID-19 on health-related quality of life in the general population: A systematic review and meta-analysis

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliations Departement of Research & Innovation, Mont Kenya University, Thika, Kenya, Department of Health Systems Management, School of Health Sciences, Nairobi Campus, Kenya Methodist University (KeMU), Meru, Kenya, College of Doctoral Studies, Grand Canyon University, Phoenix, Arizona, United States of America

Roles Conceptualization, Data curation, Methodology, Writing – review & editing

Affiliation Department of Community Health & Behavioral Sciences, School of Medicine, Masinde Muliro University of Science & Technology, Kakamega, Kenya

Roles Data curation, Methodology, Writing – review & editing

Affiliation Departement of Research & Innovation, Mont Kenya University, Thika, Kenya

Roles Formal analysis, Methodology, Writing – review & editing

Roles Methodology, Writing – review & editing

Affiliation Department of Environmental Health, Colleges of Health Sciences, Jumeira University, Dubai, The United Arab Emirates

Affiliation Department of Dermatology, International Hospital Kampala, Kampala, Uganda

Desire Aime Nshimirimana,
Donald Kokonya,
Jesse Gitaka,
Bernard Wesonga,
Japheth Nzioki Mativo,
Jean Marie Vianey Rukanikigitero

Published: October 26, 2023
https://doi.org/10.1371/journal.pgph.0002137
Peer Review
Reader Comments

The World Health Organization declared coronavirus disease of 2019 as an epidemic and public health emergency of international concern on January 30 th , 2020. Different factors during a pandemic can contribute to low quality of life in the general population. Quality of life is considered multidimensional and subjective and is assessed by using patient reported outcome measures. The aim and objective of this review is to assess the impact of coronavirus disease of 2019 and associated factors on the Quality of Life in the general population. This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A protocol was registered in the international Prospective Register of Systematic Reviews database(CRD42021269897). A comprehensive electronic search in PubMed, EBSCO Host Research Databases, MEDLINE and Google scholar search engine was conducted. A total number of 1,7000,074 articles were identified from electronic search. 25 full text articles were retained for qualitative synthesis and seventeen articles for quantitative analysis. Seven main quality of life scales were used to assess the quality of life of the general population; World Health Organization Quality of Life-bref, EuroQuality of Life-Five dimensions, Short Form, European Quality of Life Survey, coronavirus disease of 2019 Quality of Life, General Health Questionnaire12 and My Life Today Questionnaire. The mean World Health Organization Quality of Life-brief was found to be 53.38% 95% confidence interval [38.50–68.27] and EuroQuality of Life-Five dimensions was 0.89 95% confidence interval [0.69–1.07]. Several factors have been linked to the Coronavirus disease of 2019 such as sociodemographic factors, peoples living with chronic diseases, confinement and financial constraints. This review confirms that the Coronavirus disease of 2019 pandemic affected the quality of life of the general population worldwide. Several factors such as sociodemographic, peoples living with chronic diseases, confinement and financial constraints affected the quality of life.

Citation: Nshimirimana DA, Kokonya D, Gitaka J, Wesonga B, Mativo JN, Rukanikigitero JMV (2023) Impact of COVID-19 on health-related quality of life in the general population: A systematic review and meta-analysis. PLOS Glob Public Health 3(10): e0002137. https://doi.org/10.1371/journal.pgph.0002137

Editor: Anil Gumber, Sheffield Hallam University, UNITED KINGDOM

Received: April 21, 2023; Accepted: October 3, 2023; Published: October 26, 2023

Copyright: © 2023 Nshimirimana et al. 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: A protocol was registered in the international Prospective Register of Systematic Reviews database (PROSPERO) registration number (CRD42021269897).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

The World Health Organization (WHO) declared coronavirus disease of 2019 (COVID-19) an epidemic and public health emergency of international concern on January 30 th , 2020. The virus is known to have originated from Wuhan City, Hubei Province, China in December 2019. COVID-19 drew global attention due to rapid increase in the numbers reported both in China and internationally within shortest period [ 1 ]. By February 20 th , 2020, the number of contaminated COVID-19 cases in China reached a cumulative total of 75,465 cases and it had already spread to more than 25 countries among them Germany, Italy, France, Japan, Malaysia, Singapore, South Korea, Spain, Thailand, Vietnam, the United Arab Emirates, the United Kingdom (UK), the United States of America (USA) and Africa [ 2 ]. According to WHO (2021), a total of 190,597,409 confirmed cases of COVID-19, among them 4,093,145 deaths and only 3,430,051,539 vaccine doses have already been administered worldwide by 18 th July 2021. Psychological conditions such as depression, anxiety and stress can contribute to the deterioration of quality of life (QoL) of populations. A Spanish study assessed the impact of COVID-19 on mental health and find that the most prevalent mental disorders were anxiety, sleep and affective disorders as well as depression with a considerable increase in suicidal behavior among women and men over 70 years old [ 3 ]. A national study in France reported a burnout of 55% during COVID-19 pandemic and he also find out that there was a strong link between the severity of the burnout syndrome, QoL and the impact of COVID-19 pandemic [ 2 , 4 ]. Health related quality of life (HRQoL) is considered multidimensional and subjective and is assessed by patients using patient reported outcome measures (PROMs). According to WHO, HRQoL is defined as the general perception of individuals of their position in life (i) considering, the culture and value systems and (ii) in relation to expectations, goals, standards, and concerns [ 4 ]. HRQoL considers a wide-ranging concept influenced in a complex and interconnected manner by the psychological state, physical health, personal beliefs, social relationships and relationship to prominent features of the environment [ 5 ]. A systematic review discussed the impact of COVID-19 on the HRQoL on children and adolescents. Their results showed that lockdown significantly affected QoL, happiness and optimism (p < 0.001), as well as perceived stress. In their findings, the authors reported that only 15.3% (n = 146) of children and adolescents had low QoL before COVID-19 outbreak and during the pandemic, 40.2% of them reported low QoL [ 6 ]. A study conducted in the Kingdom of Saudi Arabia [ 7 ] assessed the QoL during COVID-19 in the general population and reported that being male (OR = 1.96; 95% CI = [1.31–2.94]), aged between 26 to 35 years (OR = 5.1; 95% CI = [1.33–19.37]), non-Saudi participants (OR = 1.69; 95% CI = [1.06–2.57]), individuals with chronic diseases (OR = 2.15; 95% CI = [1.33–3.48]), loss of job (OR = 2.18; 95% CI = [1.04–4.57]) and participants with depression (OR = 5.70; 95% CI = [3.59–9.05]), anxiety (OR = 5.47; 95% CI = [3.38–8.84]) and stress (OR = 6.55; 95% CI = [4.01–10.70]) were at a high risk of having lower levels of QoL during COVID-19 pandemic and lockdown period [ 7 ]. Swedish authors assessed the changes of QoL of the Swedish population using data of February and April 2020 and reported that on visual analogue scale (VAS), the mean QoL reduced from 77.1(SD:17.7) in February to 68.7(SD:68.7) in April 2020, a reduction of 8.4% pre and post pandemic measurements (P<0.000) [ 8 ]. In 2021, authors compared the QoL of Brazilian dietitians before (3.83 ± 0.59) and during COVID-19 pandemic (3.36 ± 0.66) and find that the results were statistically different [ 9 ]. To the best of our knowledge, this is one of the first systematic reviews to assess the impact of COVID-19 on HRQoL in the general population. The aim and objective of this systematic review is to assess the impact of COVID-19 and associated factors to Health Related Quality of Life in the general population.

Design and protocol

This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)( Fig 1 ) [ 10 ]. A protocol was registered in the international Prospective Register of Systematic Reviews database (PROSPERO) with the registration number CRD42021269897.

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https://doi.org/10.1371/journal.pgph.0002137.g001

Eligibility

Articles were included if they were (i) primary and empirical, quantitative, cross-sectional, cohort, case-control, peer reviewed, assessing effects of COVID-19 on the quality of life during COVID-19 in the general population, utilized validated scales for measurement, published in English language from inception to June 30 th , 2022. Articles were excluded if (ii) focusing on subgroups of populations such as health care workers, population with previous mental health, population with cancer, HIV or any other chronic disease, utilized secondary data and non-empirical, non-peer review, review articles such as scoping, narrative or Systematic reviews, papers on Medrxiv and SSRN server, comments, letters, conference abstracts, books and book chapters, articles not assessing the quality of life, papers on the population with previous mental health or papers not assessing quality of life in the general population during COVID-19 pandemic. There was no limit on the number of papers to synthetize. All articles satisfied the eligibility criteria were included. Grey literature was used only to support the background section of the research ( Table 1 ).

https://doi.org/10.1371/journal.pgph.0002137.t001

Search strategy and selection

A comprehensive electronic search in the PubMed, EBSCO Host Research Databases (Academic Research Complete), MEDLINE (OVID) and Google scholar search engine was conducted from January 5 th , 2022 to February 28 th , 2022 and updated on June 30 th , 2022. The search strategy and data extraction were designed by DAN, DK and JG using Medical Subject Headings (MeSH), field tags and relevant keywords related to quality of life, COVID-19 and general population. Boolean operators, thesaurus, truncation, nesting and quotation marks were used to strengthen the search. The full search strategy was provided in supplementary documents. Additional search of the references from retrieved systematic reviews through snow balling was performed. All retrieved papers were downloaded and saved to Mendeley for intext citations and referencing. The following was used as search string for PubMed; “("Quality of Life"[Mesh] OR “quality of life” [tw] OR “Health-related Quality of Life” [tw] OR HRQoL[tw]) AND ("COVID-19"[Mesh] OR COVID-19[tw] OR “SARS-CoV-2” [tw] OR Sars-cov-2[tw] OR Coronavirus[tw] OR SARS OR “Coronavirus disease 2019” [tw] OR “severe acute respiratory syndrome coronavirus 2” [tw] OR “2019-nCoV Infection” [tw] OR 2019-nCoV[tw] OR “COVID-19 Virus Disease” [tw]) AND (Population[Mesh] OR “general population”[tw] OR “general public”[tw] OR public[tw] OR communit*[tw]).

Data extraction technique

A standardized data collection tool to extract relevant information from papers was designed. The following data was collected; authors, country of publication, study design, sample size, demographic characteristics, HRQoL before COVID-19, HRQoL during COVID-19, QoL measurement tool, statistical tests and risk factors as well as their odds ratios (OR). Data was extracted by two authors (DAN & BW) and verified by the second author (JNM). Discrepancies were resolved by the 3 rd author (JG).

Quality appraisal

Two authors (DAN and JG) independently assessed the quality of the included papers using a modified Newcastle-Ottawa Scale (NOS) modified for cross-sectional studies. The quality criteria used in cross-sectional studies were: sample representation, sample size, response rate and validated measurement tools with appropriate cut-off points and the control of confounding variables or use of multiple regression. The quality score ranged between 0 and 5 and any study scoring > or = 3 was considered as high and any study scoring < 3 was considered to be at low quality.

Main outcome

Health related quality of life (HRQoL).

Measures of effect

Health related quality of life measurements such as means of EQ5D and WHOQoL-BREF and their standard deviations were calculated.

Heterogeneity and risk of bias assessment of included studies

Qualitative synthesis and quantitative analysis

Data was summarized following the “Institute of Medicine committee on the standards for systematic reviews of comparative effectiveness research: Finding out what works in health care; standards for systematic reviews: recommended standards for qualitative synthesis” [ 19 ] and the key characteristics of included studies if similar were grouped, synthetized qualitatively and discussed in order to draw conclusions. The mean effect size was performed and pooled for both EQ5D and WHOQoL_BREF using Random effect model. In meta-analysis, they are two classes of models; fixed and random effect models. For fixed-effect model, all studies are assumed that population effect sizes are the same and are appropriate for drawing inferences on the studies included in the meta-analysis whereas random-effect model attempt to generalize the findings beyond included studies and assume that the selected studies are random samples from a larger population. According to Dettori et al. (2022), the observed effect size is a combination of the study-specific effect and the sampling error [ 20 ]. The model is: Yi = B random+Ui+ei, where B random is the average of the true effect sizes, Ui addition of random effect, ei = error. Homogeneity of effect sizes, that is τ2 = 0 can be tested by chi-square statistic which is Q statistic. The τ2 can be used to estimate the degree of heterogeneity. τ2 also depends on the type of effect size used and the common one is I2. I2 is interpreted as the proportion of between-study heterogeneity to the total variation (between–study heterogeneity plus sampling error). When I2 is negative, it is truncated to zero. I2 of 25, 50 and 75% is considered low, moderate and high heterogeneity respectively as a rule of thumb [ 21 ]. When conducting a random effect model, it is required to estimate the amount of heterogeneity. The most widely used heterogeneity estimator in medical science is DerSimonian and Laid. Other estimators such as maximum likelihood and restricted maximum likelihood may also be used.

A total number of 1,700,074 articles were identified from electronic databases on PubMed (1,334,241), Medline (OVID) (365,401), EBSCO (Host Research Databases (Academic Research Complete)) (425) and manual search with Google scholar search engine (5). 121,211 duplicates and 1,578,317 papers not related to quality of life were removed and 546 papers were retained. 461 full text papers and abstracts were removed to retain 85 full articles for screening. Finally, 25 full text articles were included for quality synthesis. 8 full articles were excluded because there were no papers with similar instruments to compare and 17 studies were included for quantitative analysis (PRISMA) ( Fig 1 ).

Characteristics of included studies

The total sample size of included studies was N = 22,967 participants and ranges from 225 to 3,002 participants per study. The majority (64.85%) were female (n = 14,894). 3 studies were done in China [ 22 – 24 ], 2 Morocco [ 25 , 26 ], 2 Vietnam [ 27 , 28 ], 2 Italy [ 29 , 30 ], 1 Saudi Arabia [ 7 ], 1 Malaysia [ 31 , 32 ], 1 Jordan [ 33 ], 1 Philippines [ 34 ], 1 Hong Kong [ 35 ], 1 Portugal [ 36 ], 1 Israel [ 37 ], 1 Spain [ 38 ], 1 Brazil [ 39 ], 1 Scotland [ 40 ], 1 USA [ 41 ], 1 Egypt [ 42 ], 1 study done in two countries Belgium and Netherlands [ 43 ] and one in Africa, North America, Asia, Australia, Europe, South America [ 44 ]. Nine articles used the WHOQoL-BREF tool to measure the quality of life in their respective countries [ 7 , 30 – 33 , 35 , 37 , 39 , 41 ], six papers utilized the EQ-5D [ 22 , 25 , 27 , 28 , 36 , 43 ], three used SF12/SF-8/ SF36 [ 24 , 26 , 38 ], one utilized EQLS [ 40 ], one used GH12 [ 29 ], one utilized the COVID-19 QoL questionnaire [ 44 ], on used the COVID-19 (COV19- Impact on the quality of life (COV19-QoL) scale) [ 42 ] and one utilized MLT [ 34 ]. The majority of the studies (n = 23) were of cross-sectional design and only one [ 40 ] was of a mixed method. Nine studies utilized the WHOQoL-BREF [ 7 , 30 – 33 , 35 , 37 , 39 , 41 ], nine utilized the EQ-5D [ 22 , 25 , 27 , 28 , 36 , 40 , 43 ] among them two studies compared and reported QoL scores before and during COVID-19 [ 25 , 36 ], three articles utilized the SF12/SF-8/SF36 [ 24 , 26 , 38 ] one article utilized EQLS [ 40 ], one paper used GH12 [ 29 ]. Another one assessed the HRQoL using COVID-19 QoL questionnaire [ 44 ] and one article used MLT [ 34 ] to assess HRQoL in general population ( Table 2 ).

https://doi.org/10.1371/journal.pgph.0002137.t002

Measurement tools

The most used instruments in this study (WHOoQoL and EQ5D) are explained below and a brief description of their normal values for unaffected populations are given at the beginning of each reported instrument. Eight (n = 8) scales have been used to assess health related quality of life on the general population worldwide during COVID-19. EQ-5D: Euro_QoL-Five dimensions; is a preference and generic quality of life instrument to valuate and describe health related quality of life; the higher the index, the better the health. It describes health in terms of five dimensions; mobility, self-care, usual activities, pain/discomfort and anxiety/depression [ 45 ]. A utility score can be generated from the five dimensions based on a published algorithm with a value of 0 for death and 1 for perfect health. WHO_OoL-BREF: the WHO_BREF is a 26-item instrument with four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items) [ 46 ]. It is scored from 1 to 5 on a response scale but transformed linearly to a 0 to 100 scale. 0 point represent the worse possible health state while 100 points represent the best possible health state. SF12: Short form are generic health survey short-forms (don’t use preference based approach) to assess quality of life which are used in research and clinical practice, health policy and general surveys [ 47 ]. EQLS: European Quality of Life Survey is a 2012 scale which considers the following dimensions; employment and work-life balance, family and social life, health and public services, home and local environment, quality of society, social exclusion and community involvement, standard of living and deprivation, subjective well-being which is designed for the general population[ 48 ]. GHQ: General Health Questionnaire is a measure of current mental health and since its development by Goldberg in the 1970s it has been extensively used in different settings and different cultures [ 49 ]. COV19-QoL is a 6-item scale covering main areas of quality of life in relation to mental health. The first item covers patients’ feelings about the impact of the current pandemic on their quality of life in general population. The second and third include the participants’ perceptions of possible mental and physical health deterioration. COV19-QoL scale is a recently developed specific reliable and valid tool assessing perceptions of deterioration in QoL as a result of the COVID-19 pandemic [ 42 ]. MLT: My Life Today the 9-tem (4) scale was used to measure the participants’ perceptions of various life domains, including the assessment of life in general population [ 34 ].

Quality of life before and during COVID-19

Among 25 articles reporting changes in QoL, 23 reported the mean QoL only during COVID-19 and did not report the QoL before COVID-19. Nine papers [ 22 , 25 , 27 , 28 , 36 , 40 , 43 ] utilized EQ5D among them only two reported both QoL before COVID-19 as compared to that of during COVID-19 [ 25 , 36 ] using EQ5D instrument. Azizi et al. (2020) in Morocco reported an EQ5D mean score before COVID-19 of 0.91(SD: NR) and 0.86 (SD: NR) during the pandemic. This makes a drop of 0.05 on QoL. Ferreira et al. (2021) in Portugal also reported an EQ5D mean score before COVID-19 of 0.887 (SD: NR) and 0.861 (SD: NR) during COVID-19 making a drop of 0.026 of QoL. Using EQ5D, the minimum score reported during COVID-19 was 0.79 (SD: 0.17–1.41) and a maximum of 0.95 (SD:.14–1.76) with a mean score 0.89 (SD: 0.66–1.13). Among papers reporting QoL using WHOQoL, no study reported both scores (before and after) and the WHOQoL minimum score reported during COVID-19 was 13.20 (SD: 9.85, 16.55) with a maximum of 73.50 (SD:66.14, 80.86). The mean reported was 53.38 (SD:38.50, 68.27). The lower the score, the lower the QoL. The rest of quality of life instruments were used at least once making it not practical to report their means for a comparison.

Forest plot WHO_BREF

Study1 [ 7 ], study2 [ 31 ], Study3 [ 33 ], Study4 [ 35 ], Study5 [ 7 ], Study6 [ 37 ], Study 7 [ 32 ], Study8 [ 41 ], study 9 [ 50 ]. The mean health related quality of life using WHOQoL_BREF is estimated at 53.38.

https://doi.org/10.1371/journal.pgph.0002137.g002

Forest plot EQ5D

Study 1 [ 25 ], Study2 [ 43 ], Study3 [ 43 ], Study4 [ 22 ], Study5 [ 36 ], Study6 [ 23 ], Study7 [ 27 ], Study8 [ 28 ].

https://doi.org/10.1371/journal.pgph.0002137.g003

Heterogeneity and risk of bias of WHO-BREF studies

A funnel plot of the estimates is shown in ( Fig 4 ). The regression test indicated funnel plot asymmetry ( p = 0.0019) but not the rank correlation test ( p = 0.1194) ( Fig 4 ).

Study1 [ 7 ], study2 [ 31 ], Study3 [ 33 ], Study4 [ 35 ], Study5 [ 7 ], Study6 [ 37 ], Study 7 [ 32 ], Study8 [ 41 ], study 9 [ 50 ].

https://doi.org/10.1371/journal.pgph.0002137.g004

Heterogeneity and risk of bias of EQ5D studies

https://doi.org/10.1371/journal.pgph.0002137.g005

Quality assessment

We used the Modified Newcastle-Ottawa quality assessment scale tool to assess the quality of included papers and only 3 papers scored five out five (5/5) [ 29 , 36 , 39 ]. Ten papers scored four out of five (4/5) [ 7 , 22 , 23 , 30 , 31 , 33 , 35 , 38 , 42 , 44 ]. Eight studies scored three out five (3/5) [ 24 , 27 , 28 , 32 , 34 , 38 , 43 ]. Only three papers [ 25 , 26 , 40 ] scored 2 out five making it the lowest score and therefore low quality. We included the three low quality articles in the qualitative synthesis however only one low quality paper [ 25 ] was included in the quantitative analysis (meta-analysis) because it was lying within two standard deviations of the mean therefore it was not affecting the results ( Table 3 ).

https://doi.org/10.1371/journal.pgph.0002137.t003

Quality of life and factors associated to the low HRQoL

Eight studies [ 22 , 25 , 27 , 28 , 36 , 40 , 43 ] have used the EQ-5D to assess the quality of life for the general population during COVID-19 pandemic. The mean score using EQ-5D estimated at 0.89 [95% CI 0.66–1.13]. By using EQ-5D, authors [ 25 ] reported the results (before and during confinement) that the quality of life was affected in the five health dimensions; mobility 87%(87%), self-care 97%(93%), usual activities 82%(89%), pain/discomfort 70%(78%) and anxiety/depression 44%(66%). His comparison on the two samples showed that during confinement, peoples had lower scores of HRQoL at 0.86 (p<0.001) as compared to before confinement whose score was 0.91 [ 25 ]. Female gender was affected with lower scores of HRQoL than their counterpart male on both utility (0.85; P = <0.0001 and VAS (78.49; P = 0.004) and (utility = 0.89 and VAS = 83.78) respectively. Marital status was significantly associated to EQ-5D utility (P = 0.002) and VAS (P = 0.005) scores, widowed had the worst HRQoL (utility = 0.43 and VAS = 48.75) compared to single (utility = 0.87 and VAS = 80.09), married (utility = 0.86 and VAS = 81.43), and separated (utility = 0.89 and VAS = 80.15) participants. Participants with university education had the higher EQ-5D utility score (0.88; p<0.001) and age did not have a significant impact. A study done in Belgium and Netherlands also evaluated the quality of life using EQ5D as well, a minority in both countries felt stressed with 27% and 14% respectively [ 43 ]. The majority reported concerns about their personal current and future financial situation (59 and 48% respectively) and the national economies (88 and 86%). Specifically, in Belgium, the EQ-5D before COVID-19 measured 0.82 (95% CI; 0.80–0.84) and during COVID-19 measures 0.79 (95% CI; 0.77–0.81). In Netherlands, before COVID-19, 0.85 (95% CI; 0.83–87) and during COVID-19 outbreak, it was 0.84 (95% CI; 0.82–0.86). Chen et al. (2021), using EQ5D concluded that the mean EQ-5D score and VAS were 0.99 and 93.5. Their multiple linear regression showed that the quality of life measure was related to physical activities (β = 0.006) and keeping home ventilation (β = 0.063) in Daqing, and were related to wearing a mask when going out (β = 0.014), keeping home ventilation (β = 0.061), other marital status (β = − 0.011), worry about the epidemic (β = − 0.005) and having a centralized or home quarantine (β = − 0.005) in Taizhou [ 22 ]. Using EQ5D, authors concluded that those quarantined at home experienced higher levels of anxiety and a lower HRQoL compared with the pre-COVID-19 pandemic population. Females and elderly individuals experienced the highest levels of anxiety and poorest HRQoL (OR not reported) [ 36 ]. Other authors [ 23 ] using the same instrument EQ5D reported that the risk of pain/discomfort and anxiety/depression in general population in China raised significantly with aging, with chronic disease, lower income, epidemic effects, worried about get COVID-19 during the COVID-19 pandemic (OR not reported) [ 23 ]. Tran et al. (2020) With the same instrument EQ5D (n = 341) reported that 66.9% of household income loss was due to the impact of COVID-19. The mean score of EQ-5D and EQ-VAS was 0.95 (SD ± 0.07) and 88.2 (SD ± 11.0) respectively. The domain of Anxiety/Depression had the highest proportion of reporting any problems among 5 dimensions of EQ-5D (38.7%). Being female, having chronic conditions and living in the family with 3–5 members were associated with lower HRQOL score (OR not reported) [ 27 ]. Vu et al. (2020) using EQ5D reported the highest mean EQ-VAS at 90.5 (SD: 7.98) among people in government quarantine facilities, followed by 88.54 (SD: 12.24) among general population and 86.54 (SD 13.69) among people in self-isolation group [ 28 ]. The EQ-5D value was reported as the highest among general population at 0.95 (SD: 0.07), followed by 0.94 (SD: 0.12) among people in government quarantine facilities, and 0.93 (SD: 0.13) among people who put themselves in self-isolation. Overall, most people, at any level, reported having problems with anxiety and/or depression in all groups.

WHOQoL-BREF.

The WHOQoL average scores was estimated at 50.55% 95% CI [32.19–68.90]. Authors by using WHOQoL-BREF reported a quality of life affected with a score of 39% (CI not reported) and according to authors, males were more affected with OR = 1.96 (95% CI = 1.31–2.94); participants aged 26 to 35 years OR = 5.1; (95% CI = 1.33–19.37); non-Saudi participants OR = 1.69 (95% CI = 1.06–2.57); individuals with chronic diseases OR = 2.15 (95% CI = 1.33–3.48); those who lost their job OR = 2.18 (95% CI = 1.04–4.57) and those with depression OR = 5.70 (95% CI = 3.59–9.05), anxiety OR = 5.47; (95% CI = 3.38–8.84), and stress OR = 6.55 (95% CI = 4.01–10.70) [ 7 ].

In 2021, a study [ 31 ] concluded that higher psychological QoL reduced the odds of depressive symptoms OR = 0.83 (95% CI = 0.69–0.99, p = 0.032) and depressive with comorbid anxiety symptoms OR = 0.82, (95% CI = 0.68–0.98, p = 0.041), whereas higher physical health QoL OR = 0.85, (95% CI = 0.75–0.97, p = 0.021) and social relationship QoL OR = 0.70 (95% CI = 0.55–0.90, p = 0.009) reduced the odds of anxiety symptoms [ 31 ]. In 2020, a study [ 33 ] had reported a mean for total QoL score of 73.21 (SD ¼ 16.17). The mean general QoL and health scores were 3.15 (SD ¼ 0.94) and 3.40 (SD ¼ 0.95). As for the four QoL subscales, the mean scores in each domain were as follows: 18.04 (SD ¼ 4.39) for physical health, 17.65 (SD ¼ 3.77) for psychological health, 8.69 (SD ¼ 2.67) for social relationships, and 22.29 (SD ¼ 5.84) for environment(29). Choi et al (2021), using the same QoL scale reported that 69.6% of participants were worried about contracting COVID-19, and 41.4% frequently suspected themselves of being infected whereas 29.0% were concerned by the lack of disinfectants. All of these findings were associated with poorer HRQoL in the physical and psychological health, social relationships, and environment domains (OR not reported). 47.4% of participants were concerned that they may lose their job because of the pandemic and 39.4% were bothered by the insufficient supply of surgical masks [ 35 ]. The results of a study [ 30 ] showed statistically significant difference in QoL depending on a number of variables, including sex, area of residence in Italy, and being diagnosed with a medical/psychiatric condition (OR: NR). The overall average score at the WHOQoL-BREF was 54.48 (SD = 7.77). The item with the lowest scores was 14 (about the use of spare time), given that 932 (41.4%) participants reported to have little or no time for leisure at the time of data collection. Regarding the other three domains of the WHOQoL, items with lowest scores were: item 15 for the physical domain, as 1019 (45.3%) participants reported little or no possibility to do physical activity; item 5 for the psychological domain, with 712 (31.6%) respondents reporting that they were not enjoying their lives at the time of data collection, and item 21 for social relationships, as 843 (37.4%) respondents reported that they were little or not at all satisfied with their sexual life [ 30 ]. A research in 2021 [ 37 ] reported that COVID-19 has had a wide impact on the general population, with the potential for negative secondary impacts. Women, young adults, and the unemployed are at high risk for secondary effects (ORs:NR). Another study [ 39 ] scores on the social relationships QoL domain were lower among participants who had a family member or friend with COVID-19 and among those who engaged in negative forms of spiritual religious coping (SRC). The quarantine during the COVID-19 pandemic has limited personal contact with family and friends, adversely affected sexual activity, and has restricted other activities that are assessed in the social relationships QoL domain. Positive forms of spiritual religious coping (SRC) were associated with better scores on this domain, as reported in other studies [ 37 ]. In 2020, a study [ 32 ] highlighted that approximately one in three individual experienced mild-to-severe depressions during the nationwide movement control order (MCO). The results of a study [ 41 ] reported that most would expect quality of life to be challenged during a global pandemic; however, when behavioral health assessed as a component of overall quality of life, longer term outcomes became concerning [ 41 ].

SF12/SF-8/ SF36.

Samlani et al. (2020) by using SF 12/8 (Chinese) scale, all participants obtained a total average score of 70.60 (±13.1) with a mental health score (MCS) of 34.49 (±6.44) and a physical health score (PCS) of 36.10 (± 5.82). The physical (PCS) and mental (MCS) scores of participants with chronic diseases were 32.51 (±7.14) and 29.28 (±1.23), respectively. Overall, the participants’ PCS and MCS scores suffered from chronic diseases and the elderly participants were lower than those of young participants without comorbidities(23). López et al (2021) reported the following results using SF-36; the presence of pain in subjects undergoing confinement was persistent, with varying intensity and frequency based on age, gender, physical activity, and work status (OR:NR). In any of these conditions, the quality of life of the subjects in confinement has been severely affected [ 38 ]. Qi et al. 2020 using–SF8 (Chinese), participants’ average physical component summary score (PCS) and mental component summary score (MCS) for HRQoL were 75.3 (SD = 16.6) and 66.6 (SD = 19.3), respectively. More than half of participants (53.0%) reported moderate levels of stress. Significant correlations between physical activity participation, QoL, and levels of perceived stress were observed (p < 0.05). Prolonged sitting time was also found to have a negative effect on QoL (p < 0.05) [ 24 ].

Campbell & Davison (2022) by using EQLS found that there are strong relationships between QoL and income, disability and living arrangement as well as social isolation and Disability and living arrangement [ 40 ]. Correlation and multiple regression analyses showed a strong relationship between social isolation, gratitude, uncertainty and QoL with social isolation being a significant predictor (OR not reported).

Bonichini & Tremolada (2021) reported that the mean GH12 score in participants amounted to 17.86 (SD = 5.85), reflecting a contingent moderate stressful impact on QoL. GH12 identified 39% of respondents as having subclinical QoL scores (score ≥ 15). 24.5% of such respondents as having very problematic scores (score ≥ 19), and 36.5% of such respondents as having normal scores (score < 15). Analysis of variance (ANOVA) showed there was a significant difference (F(2, 1.836) = 5.50, p = 0.004, η 2 = 0.01) in mean GH12 scores [ 29 ].

COVID-19 QoL questionnaire.

The results of Khodami et al. (2022) showed that Quality of life is significantly decreased over time, perceived stress level raised significantly and an increased level of difficulty in emotion regulation has happened. Younger peoples and individuals who had a worsening quality of life response tended to show more stress and emotion regulation problems [ 44 ]. Mohsen et al. (2022) using COVID-19 on Quality of life scale reported that the total COV19-QoL scale score was 2.3±0.6. Two items show the highest mean with 2.6±0.7 (quality of life in general and perception of danger on their personal safety) indicating the poorest quality of life regarding these 2 items. However, the lowest mean score was related to the perception of mental health deterioration (1.9±0.8). Significant variables in the bivariate analysis revealed that sex (regression coefficient = 0.1 (95% CI(0.02 to 0.2), p value = 0.02), monthly income (regression coefficient (95% CI) = 0.1 (0.004 to 0.2), p value = 0.04), knowing someone infected with COVID19 (regression coefficient (95% CI) = 0.15 (0.08 to 0.3), p value = 0.001), and data collection time (regression coefficient (95% CI) = 0.1 (0.006 to 0.2), p value = 0.04) were the independent predictors for overall QoL scale score [ 42 ].

Aruta et al. (2022) by using MLT questionnaire, the results of the path analysis indicated a good data‐model fit: (χ 2 = 4.97, df = 2, p = 0.08; CFI = 0.99, TLI = 0.96, SRMR = 0.02, RMSEA [90% CI] = 0.06 [0.000 − 0.13]). The direct effects of safety at home (B = −0.27, β = −0.21, SE = 0.05, p ≤ 0.001), TPIs (B = −0.19, β = −0.27, SE = 0.05, p ≤ 0.001), and financial difficulties (B = 0.15, β = 0.18, SE = 0.05, p ≤ 0.001) on psychological distress were found to be significant. Direct effects of safety at home (B = 0.19, β = 0.22, SE = 0.05, p ≤ 0.001), TPIs (B = 0.18, β = 0.27, SE = 0.04, p ≤ 0.001), financial difficulties (B = −0.15, β = −0.21, SE = 0.05, p ≤ 0.001), and psychological distress (B = −0.29, β = −0.34, SE = 0.04, p ≤ 0.001) on quality of life were found to be significant. Results indicated that psychological distress partially mediated the positive influence of safety at home (B = 0.06, β = 0.07, SE = 0.02, p ≤ 0.001) and TPIs (B = 0.06, β = 0.09, SE = 0.02, p ≤ 0.001) on quality of life [ 34 ]. These findings indicate that psychological distress is a mechanism that can partly explain why socio‐ ecological factors (i.e., safety at home, financial difficulties, and trust in institutions) impact the quality of life of Filipino adults during COVID‐19.

Findings of included studies demonstrated how COVID-19 pandemic reduced the QoL of the general population. Different factors influenced directly or indirectly the change of QoL. Researchers utilized different quality of life measurement scales among them EQ-5D leading the pool of measurement scales followed by WHOQoL-BREF then SF12/SF-8/ SF36 as 3 rd scale and the rest. For studies that used EQ-5D to assess the impact of quality of life, all five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) were affected significantly with a mean EQ-5D score of 0.89 with 95% CI [-1.865–2.048] with the lowest score of 0.79 at 95% CI (NR) and upper score of 0.99 at 95% CI (NR) [ 25 ]. The mean WHOQoL-BREF score was estimated at 50.55 with a 95% CI [32.19, 68.90]. Other instruments such as SF12 scored 70.60 with 95% CI [57.5, 83.7], SF8 scored QoL at 75.3 with 95% CI [58.7, 91.9] and SF36 (score NR). In low and middle income countries (LMICs) such as Morocco [ 25 ] using EQ-5D reported low QoL during confinement as compared to before in the 5 health dimensions respectively; mobility 87%(87%), self-care 97%(93%), usual activities 82%(89%), pain/discomfort 70%(78%) and anxiety/depression 44%(66%) with average QoL at 0.91 (p<0.001) before and 0.86 (0.001) after confinement. Whereas in high income countries (HICs), Belgium for example using EQ-5D before COVID-19 QoL measured 0.82 (95% CI; 0.80–0.84) and during COVID-19 measures 0.79 (95% CI; 0.77–0.81), the same with Netherlands, before COVID-19 EQ-5D measured 0.85 (95% CI; 0.83–0.87) before and during COVID-19 0.84 (95% CI; 0.82–0.86). A research in China, using EQ5D concluded that the mean EQ-5D score and VAS were 0.99 before COVID-19 and 93.5 during COVID-19. When compared HICs and LMICs, both countries were affected significantly by COVID-19 and this was exacerbated by confinement [ 51 ]. These results are in line with those of a Chinese study with an average score EQ-5D of 0.949 and VAS score 85.52 [ 22 ]. Nine published papers assessed QoL using WHOQoL [ 7 , 30 – 33 , 35 , 37 , 39 , 41 ] and their mean score was 50.55% with 95% CI [32.19–68.90]. The lower the score, the lower the quality of life. On the other hand, using EQ-5D, the mean score was estimated at 0.89 with 95% CI [0.66–1.13] with the same trend, the lower the score, the lower the quality of life. Our study findings are different from those published in Vietnam that reported EQ5D score 0.95 (SD = NR.) during the national social distancing, against our results (mean EQ5D = 0.89) [ 27 ]. This might be because it is an empirical study while our study summarizes results from a variety of studies making our mean score low. Our main findings rely most on EQ5D and WHOQoL instrument reports. Although, we assessed QoL of the general population during COVID-19 (Mean EQ5D = 0.89), some authors assessed the impact of some chronic diseases on QoL of the general population such as type 2 diabetes [ 52 ] (EQ5D = 0.8 SD = 0.20), human immunodeficiency virus (HIV) [ 53 ] (EQ5D = 0.8 SD = 0.2), skin disease [ 54 ] (EQ5D = 0.73 SD = 0.19), respiratory diseases (EQ5D = 0.66 SD = 0.31), dengue fever (EQ5D = 0.66 SD = 0.24), frail elderly in Vietnam [ 55 ] (EQ5D = 0.58 SD = 0.20), elderly after fall injury and facture injuries (EQ5D = 0.46 SD = NR). QoL in general population during COVID-19 was comparable to that of type2 diabetes and HIV. This may be because Type2 diabetes and HIV are chronic conditions, patients are stable on medication if the management and compliance to medications is respected. QoL of skin disease patients, respiratory diseases, dengue fever, frail elderly, elderly after fall and fracture injuries were low as compared to COVID-19 general population. This may be due to the high score of pain involved in these conditions. Different factors that contributed to low quality of life have been identified; age, gender, education level, marital status, financial constraints, confinement, fear of being contaminated and individual with other chronic conditions. The two measurement scales were the most utilized instruments as compared to the other scales and their results show a considerable reduced quality of life. Using WHOQoL-BREF [ 7 ] reported a quality of life affected with a score of 39% (CI = NR) and according to authors, males were more affected probably because in developing countries, males are responsible of financial support to the family and because of that, they may fear either confinement that affects job market or else being contaminated and not able to work for their families. Concerning age, participants aged 26-35years were more affected and the reason may be because most peoples of this age bracket are the young couples or single mothers therefore the young fathers were worried about their families and finances if they are quarantined. Females were more affected than their counterparts according to [ 25 ] this may be due to the fact that females naturally are the nuclear parts of a family and their emotions towards the family therefore become much worried than males. Widowers had the worst quality of life and this may be due to their worries about their life and that of their children with less psychological support [ 56 , 57 ] from their spouses. Individuals with chronic diseases (hypertension, Type2 diabetes, asthma, stress, anxiety, depression, etc…) had a high risk of low quality of life and this might be because they are vulnerable to COVID-19 with high fear of contamination therefore pushing them to low quality of life. Other factors such as confinement, financial constraints, fear of being contaminated with COVID-19 and having a contaminated family member increased the likelihood of anxiety, stress and depression therefore leading to the low individual quality of life [ 58 ]. The main reason of stress due to confinement is due to financial constraint because a confined person is not allowed to work and generate income to sustain the family during the pandemic. It is surprising that both low and high income countries were affected by COVID-19 reducing their population quality of life. This shows how no country in the world was prepared for any huge health pandemic whether rich or poor. This highlights the low level of preparedness for countries to face similar catastrophic situations. What is lacking? Is it the money or strategies? Developed countries can afford to provide necessary means to fight against pandemics but there is no guaranty to protect the populations from dying before actions are in place. For this purpose, there is a need to strengthen infectious disease predictions and modeling using machine learning or artificial intelligence. There is a need to embrace and exploit artificial intelligence to improve the prediction of future events to prevent populations from diseases and death and maintain their maximum quality of life.

Strengths and weaknesses

First and the foremost, the strength of this review is that, it was conducted according to the international guidelines for systematic reviews after registration of the protocol in international database PROSPERO. Secondly, it was conducted two and half years after the pandemic begun and authors already have published enough papers to allow robust systematic synthesis of results. And the results can be generalized as papers were searched Worldwide with a reasonable sample size (22,967 participants).

There were also some limitations; We searched papers in English only leaving probably out some studies. The fact that we searched only 3 databases and a search engine, some articles might have been missed. The generalizability should be done with caution. Most studies reported the mean QoL during COVID-19 with no baseline to compare, this can weaken our results. All studies were cross-sectional and there were no cohort or case control studies, this can also weaken our conclusions.

This systematic review confirms that the COVID-19 pandemic affected negatively health related quality of life of the general population. Several factors influencing quality of life of general population through COVID-19 have been identified; age, sex, marital status, education, peoples living with chronic diseases, confinement and financial constraints among others, etc…. There was no significant difference between the impact of COVID-19 in general population in high income countries and low and middle income countries. Three quality of life scales were mainly used to assess the quality of life of the general population; WHO-QoL-BREEF, EQ-5D, SF and others. The findings of this review will be useful for policy makers and health managers to facilitate the planning and prevention of quality of life of the general population during future pandemics. We recommend cohort and case control studies on impact of COVID-19 on quality of life to collect more and strong evidence on impact of COVID-19 on different population in the world. We are also recommending studies on prediction and modeling of infectious diseases using machine learning and artificial intelligence to prevent the population from future pandemics to maintain the population quality of life.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pgph.0002137.s001

S1 Table. Summary of included studies.

https://doi.org/10.1371/journal.pgph.0002137.s002

S1 Text. PubMed search string.

https://doi.org/10.1371/journal.pgph.0002137.s003

Acknowledgments

The authors acknowledge the moral support from their families, friends and colleagues.

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19. Institute of Medicine (US) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research. Finding What Works in Health Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S, editors. Washington (DC): National Academies Press (US); 2011. https://doi.org/10.17226/13059

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COVID-19, caused by the coronavirus, significantly impacted global health and daily life. Action plans focused on prevention, treatment, and vaccination. Some sought religious exemptions from mandates. A health thesis statement might explore the pandemic’s effects on mental health. The tone is informative and serious. This paragraph highlights the comprehensive response to COVID-19.

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Covid-19 is a global pandemic caused by the novel coronavirus. It has significantly impacted daily life, with governments worldwide implementing lockdowns, social distancing, and mask mandates to curb the virus’s spread. The pandemic has highlighted the importance of healthcare systems and the need for vaccines. It has also emphasized global cooperation and resilience in facing unprecedented challenges.

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Covid-19, caused by the novel coronavirus, has had a profound impact on the world since its outbreak. The pandemic led to widespread lockdowns, social distancing measures, and mandatory mask-wearing to prevent the virus’s spread. Healthcare systems were overwhelmed, emphasizing the need for robust medical infrastructure and preparedness. The development and distribution of vaccines became a global priority, showcasing the importance of scientific research and international cooperation. Economies faced significant challenges, with businesses closing and unemployment rates rising. Despite these hardships, the pandemic also brought communities together, highlighting resilience, adaptability, and the critical role of healthcare workers in combating the crisis.

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Covid-19, caused by the novel coronavirus SARS-CoV-2, emerged in late 2019 and rapidly spread across the globe, leading to an unprecedented pandemic. The virus’s high transmission rate prompted governments worldwide to implement stringent measures such as lockdowns, social distancing, and mask mandates to control its spread. These measures, while necessary, significantly disrupted daily life, impacting economies, education, and social interactions. Healthcare systems were strained, underscoring the need for better preparedness and robust medical infrastructure. The rapid development and global distribution of vaccines became a beacon of hope, demonstrating the power of scientific collaboration and innovation. The pandemic also highlighted the disparities in healthcare access and the importance of public health initiatives. Despite the immense challenges, communities showed resilience and adaptability, finding new ways to connect and support each other. The dedication of healthcare workers and the collective effort to combat the virus underscored the importance of global solidarity. Covid-19 has reshaped our world, teaching valuable lessons about preparedness, the significance of science, and the strength of human resilience in the face of adversity.

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Covid-19, caused by the novel coronavirus SARS-CoV-2, represents an unprecedented global health crisis. The pandemic has led to widespread implementation of public health measures such as lockdowns, social distancing, and mandatory mask usage to mitigate the virus’s transmission. Healthcare systems worldwide faced significant strain, highlighting the critical need for robust medical infrastructure and emergency preparedness. The rapid development and distribution of vaccines have been pivotal in controlling the spread of the virus, underscoring the importance of scientific research and international cooperation. The pandemic has also revealed existing disparities in healthcare access and emphasized the necessity of coordinated global public health strategies to effectively manage such crises.

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Covid-19 has really shaken things up since it started spreading in late 2019. Caused by a new coronavirus, it led to lockdowns, social distancing, and everyone wearing masks. Daily life changed a lot, with schools and businesses shutting down, and everyone trying to stay safe. The healthcare system was hit hard, showing us just how important it is to be prepared. Vaccines were developed super quickly, giving us hope to get back to normal. Even though it was tough, people came together, supported each other, and adapted to the new normal. Covid-19 taught us a lot about resilience and the importance of healthcare.

Persuasive Tone

Covid-19, caused by the novel coronavirus, has highlighted the urgent need for better healthcare systems and global cooperation. The pandemic led to widespread lockdowns, social distancing, and mask mandates, disrupting daily life and economies. Our healthcare systems were overwhelmed, underscoring the critical need for robust medical infrastructure. The rapid development of vaccines showcased the power of scientific research and international collaboration. Now, more than ever, it is crucial to support and strengthen our healthcare systems, invest in scientific research, and promote global cooperation to ensure we are better prepared for future health crises. Let’s learn from this pandemic and build a stronger, healthier world together.

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Reflecting on the impact of Covid-19, it’s clear that the pandemic has reshaped our world in profound ways. The novel coronavirus led to unprecedented global lockdowns, social distancing, and mask mandates, dramatically altering daily life. Our healthcare systems were tested like never before, revealing both strengths and weaknesses. The rapid development and distribution of vaccines highlighted the importance of scientific innovation and international cooperation. Amid the challenges, communities showed remarkable resilience and adaptability, finding new ways to connect and support one another. Covid-19 has taught us valuable lessons about preparedness, the significance of healthcare, and the power of human resilience in the face of adversity.

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Covid-19 has been a challenging journey, but it has also shown the incredible strength and resilience of humanity. The novel coronavirus led to global lockdowns, social distancing, and mask mandates, changing our daily lives dramatically. Despite these hardships, the rapid development and distribution of vaccines brought hope and showcased the power of scientific innovation and global cooperation. Communities came together, supporting each other and adapting to new realities. Healthcare workers became heroes, showing unparalleled dedication and bravery. Covid-19 has taught us the importance of unity, resilience, and the ability to overcome even the toughest challenges. Together, we can build a brighter, healthier future.

Optimistic Tone

Covid-19, caused by the novel coronavirus, brought significant challenges, but it also highlighted the resilience and adaptability of people worldwide. The pandemic led to lockdowns, social distancing, and mask-wearing, changing our daily routines. Despite these difficulties, the rapid development of vaccines brought hope and demonstrated the power of scientific progress. Communities came together, supporting one another and finding new ways to connect. Healthcare workers showed incredible dedication, and the world witnessed the strength of human spirit. Covid-19 has been a tough journey, but it also reinforced our ability to overcome adversity and work towards a healthier, more connected future.

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The Covid-19 pandemic, caused by the novel coronavirus, demands our immediate attention and action. Since its outbreak, the virus has led to widespread lockdowns, social distancing, and mandatory mask usage, significantly disrupting daily life. Healthcare systems have been overwhelmed, highlighting the urgent need for better preparedness and robust medical infrastructure. The rapid development of vaccines has been crucial, but we must continue to prioritize public health measures and global cooperation to combat this crisis. Now is the time to invest in healthcare, support scientific research, and work together to overcome this pandemic. Immediate action is essential to protect lives and prevent further devastation.

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The psychosocial impact of the covid-19 pandemic on italian families: the perception of quality of life and screening of psychological symptoms.

1. Introduction

2. materials and methods, 2.1. participants, 2.2. procedure, 2.3. instruments, 2.3.1. sociodemographic questionnaire, 2.3.2. revised children’s manifest anxiety scale—second edition, 2.3.3. chia, 2.3.4. pedsqol 3.0 multidimensional fatigue scale, 2.4. plan of statistical analyses, 3.1. perceptions of anxiety, anger, and quality of life of children and adolescents compared to norms, 3.2. comparison of quality of life scores between parents and children, 3.3. what are the factors that influence anxiety symptoms in children and adolescents, 3.4. what are the factors that influence the perceived quality of life of children and adolescents, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Click here to enlarge figure

	Statistics					Frequencies
		Min	Max	M	SD
Children’s Age		6	16	12.44	2.74
Children’s Gender	Male Female					60 71	45.8% 54.2%
Children’s School Level	Primary School Secondary School, 1st Secondary School, 2nd					35 50 46	26.7% 38.2% 35.1%
Parental Age		30	66	46.46	6.02
Parent’s Gender	Male Female					26 105	19.8% 80.2%
Parental Schooling Years		5	20	13.82	3.42
Parental Civil Status	Single Parent Two Parents					10 121	7.6% 92.4%
Parental Perceived Economic Condition	Low Medium High					23 72 36	16.6% 55.0% 27.5%

	QoL General		QoL Sleep		QoL Cognition		Total QoL Total
	Freq.	Perc.	Freq.	Perc.	Freq.	Perc.	Freq.	Perc.
Very Low QOL	1	0.8%	6	4.6%	6	4.6%	0	0%
Low Quality of Life	21	16%	19	14.5%	21	16%	14	10.7%
Moderate QoL	72	55%	75	57.3%	65	49.6%	88	67.2%
Good QoL	37	28.2%	31	23.7%	39	29.8%	29	22.1%
Total	131	100%	131	100%	131	100%	131	100%

	QoL General		QoL Sleep		QoL Cognition QoL Total
	Freq.	Perc.	Freq.	Perc.	Freq.	Perc.	Freq.	Perc.
Very Low QOL	8	6.1%	0	0%	4	3.1%	1	0.8%
Low QoL	36	27.5%	16	12.2%	30	22.9%	25	19.1%
Moderate QoL	66	50.4%	67	51.1%	50	38.2%	76	58%
Good QoL	21	16%	48	36.6%	47	35.9%	29	22.1%
Total	131	100%	131	100%	131	100%	131	100%

	Model	Anova					Coefficients
	R-Square	Df	F	p	Beta	T	P
Model	0.15	3	7.6	0.0001
Sex					0.22	2.68	0.008 *
Parents of PEDS TOT Self-Report					−0.197	−2.40	0.018 *
Total Anger					0.24	2.93	0.004 *

	Model	Anova					Coefficients
	R-Square	Df	F	p	Beta	T	P
Model	0.33	2	31.67	0.0001
Physiological Anxiety					−0.34	−4.12	0.0001 *
Social Anxiety					−0.32	−3.90	0.0001 *

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Share and Cite

Incardona, R.M.; Tremolada, M. The Psychosocial Impact of the COVID-19 Pandemic on Italian Families: The Perception of Quality of Life and Screening of Psychological Symptoms. Pediatr. Rep. 2024 , 16 , 519-529. https://doi.org/10.3390/pediatric16020043

Incardona RM, Tremolada M. The Psychosocial Impact of the COVID-19 Pandemic on Italian Families: The Perception of Quality of Life and Screening of Psychological Symptoms. Pediatric Reports . 2024; 16(2):519-529. https://doi.org/10.3390/pediatric16020043

Incardona, Roberta Maria, and Marta Tremolada. 2024. "The Psychosocial Impact of the COVID-19 Pandemic on Italian Families: The Perception of Quality of Life and Screening of Psychological Symptoms" Pediatric Reports 16, no. 2: 519-529. https://doi.org/10.3390/pediatric16020043

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Exploring COVID-19’s Impact On Undergraduate Nursing Students

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The researchers aimed to assess the effects of the COVID-19 pandemic on nursing education through semi-structured interviews with undergraduate nursing students. The researchers explored themes related to online education, clinical placements, and mental health. Findings revealed that the sudden shift to online learning caused increased stress, and decreased confidence. Clinical placements were affected, leading to missed time and altered learning experiences. Mental health suffered as students faced stressors and challenges brought on by the pandemic. These interviews elucidate the challenges faced by nursing students during the COVID-19 pandemic and provide valuable information for future planning in nursing education during crises.

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By Patrick Skerrett June 22, 2024

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“Long Covid feels like a gun to my head,” by Rachel Hall-Clifford

Thank you for this. I’m a 65-year-old woman who’s Covid cautious and wears a mask in public places (yes, in 2024). I’ve never had Covid as far as I know, and I try to keep up with the research. I feel like everybody would be more cautious if they read this article on long Covid, because it helps to really understand the horrible ways that a mild case of Covid can affect your life in ways that are unimaginable.

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“I’m a hypochondriac. Here’s how the health care system needs to deal with people like me,” by Hal Rosenbluth

Health anxiety is the less biased term, rather than hypochondria with all its comic baggage.

Though the writer likes full body scans for himself and they suit his particular fears, many, many people with health anxiety, including me, wouldn’t get within 10 feet of a full body scan. It would be the opposite of reassuring.

Even if it did reassure for the moment, anyone with health anxiety knows reassurance is short-lived. A scan done in, say, January, might reassure a non-anxious person for the next six months. But it would be the rare person with health anxiety who would feel reassured for more than a couple of weeks.

And why on earth would you want to create a separate billing code for this, which would, without question, be used to pick out, stigmatize, and limit access to medical care? That doesn’t help patients, it soothes and enriches insurers, who would undoubtedly limit access to care based on a scan. How long would it take before you called to make an appointment with your doctor and were told sorry, your insurance won’t cover an office visit — your scan said you have no problems?

The writer’s personal experience, psychology, and taste for scans are just that, personal. They don’t generalize to most, or even many, of those who suffer from health anxiety.

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I agree with the authors that NIH needs reform. I was an athletic, otherwise healthy person who was struck down and disabled by long Covid in January 2022. For over two years, I’ve watched life pass me by as NIH has fumbled the $1.15 billion allocated to it by Congress to study and treat long Covid. This initiative, known as RECOVER, has failed to publish any research that furthers our understanding of the underlying cause of long Covid and the vast majority of clinical trials they’ve launched are for drugs that people have already tried and found unhelpful.

Perhaps NIH would not have bungled the long Covid funding had it not completely ignored other post viral diseases, namely myalgic encephalomyelitis (ME) for the past 40 years. ME receives only $15 million a year — the most underfunded disease per patient burden at the NIH.

NIH should reevaluate how it allocates funding to diseases and base allocations on objective patient burdens. HIV, a disease with treatments that allow people with it to live mostly normal lives, receives $3.3 billion annually through NIH. Meanwhile, ME patients are disabled, have no approved treatments, and suffer a higher patient burden. Covid long haulers are suffering the same fate, many struck down as first wavers in March of 2020 are still disabled and sick as ever over four years later. Despite this, there is still no yearly allocation for long Covid in NIH’s baseline budget, as funding has only ever come from one time appropriations. NIH should right-size funding for ME and long Covid and start taking these diseases seriously.

— John Bolecek, long Covid patient

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Thank you for writing this essay on the trauma and burnout that are all too common among today’s health care workforce. I applaud you for underscoring the importance of trauma-informed organizations and the critical value of workplaces that are safe, supportive, and flexible.

As a nurse educator and researcher, I have come to understand the important role of resilience in the work that nurses do. Considering two-thirds of nurses (65%) experience burnout, resilience-building skills are critical to mitigating nurse exhaustion and preserving our nation’s nursing pipeline. If actions are not taken to better protect the physical and mental health of our healthcare workforce, patient care will suffer. Lawmakers must take notice.

Some efforts in Congress have been successful. Congress has introduced legislation to reauthorize the Dr. Lorna Breen Provider Protection Act , bipartisan legislation that recognizes the need for mental health resources and support programs for healthcare professionals. Since its original enactment, this act has been instrumental in funding grant programs for mental health training, education, peer support, and crisis intervention services.

The reauthorization of this measure would expand grants to more than 200,000 other types of health care settings as well as renew the focus on reducing administrative burden for health care workers. While this bill is not a perfect solution, it does provide needed to support for a workforce that is understaffed, overworked, and in need to relief.

I urge Congress to finish the job and fully reauthorize the Dr. Lorna Breen Provider Protection Act this year.

— Stephanie Turner, R.N., Ed.D., M.S.N., ATI Nursing Education

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Impact of COVID-19 and GP appointment availability on continuity of care in English general practices

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Fewer GP appointments and the COVID lockdown have exacerbated declining continuity of care in English general practices.

A lack of available appointments and the aftermath of the COVID pandemic have exacerbated declining continuity of care in General Practices across England.

Being able to get an appointment at GP surgeries and to see the same doctor improves patient health, is a more cost-effective use of healthcare resources, and is popular.

A new study, led by the University of Leicester, analyzed data across 6,010 English practices between 2018 and 2022, using continuity data from the General Practice Patient Survey which showed that fewer patients both had and were able to see a preferred doctor in their practices.

The national average dropped from 29.3 per cent to 19 per cent of patients in just four years, with the decline steepening following the COVID-19 lockdown. Although the decline occurred across all types of practices, differences between practices widened over this period.

The study examined a range of factors related to both patients and their practices in order to determine whether any were linked to the rate at which continuity was declining. These included the percentage of patients with White ethnicity, the numbers of GPs and nurses per 10,000 patients, and the percentage of patients reporting being able to get a same day appointment, as well as the practice's deprivation score and region in England.

Our study showed slower declines in continuity in practices with more doctors and with higher percentages of patients seen on the same day as booking. However, continuity declined more quickly in practices where continuity had previously been better, where there were higher percentages of patients of White ethnicity, or practices located in many areas outside of London." Dr. Steven Levene, Lead Author, Department of Population Health Sciences, University of Leicester

The rate of declining continuity was not associated with deprivation, whether the practice was urban or rural, practice size, nurse numbers, NHS contract type or NHS practice funding.

The study has now been published in the journal Annals of Family Medicine.

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Impact of COVID-19 on the social, economic, environmental and energy domains: Lessons learnt from a global pandemic

a School of Information Systems and Modelling, Faculty of Engineering and Information Technology, University of Technology Sydney, NSW 2007, Australia

I.M. Rizwanul Fattah

Md asraful alam.

b School of Chemical Engineering, Zhengzhou University, Zhengzhou 450001, China

A.B.M. Saiful Islam

c Department of Civil and Construction Engineering, College of Engineering, Imam Abdulrahman Bin Faisal University, Dammam 31451, Saudi Arabia

Hwai Chyuan Ong

S.m. ashrafur rahman.

d Biofuel Engine Research Facility, Queensland University of Technology (QUT), Brisbane, QLD 4000, Australia

e Tarbiat Modares University, P.O.Box: 14115-111, Tehran, Iran

f Science and Math Program, Asian University for Women, Chattogram 4000, Bangladesh

Md. Alhaz Uddin

g Department of Civil Engineering, College of Engineering, Jouf University, Sakaka, Saudi Arabia

T.M.I. Mahlia

COVID-19 has heightened human suffering, undermined the economy, turned the lives of billions of people around the globe upside down, and significantly affected the health, economic, environmental and social domains. This study aims to provide a comprehensive analysis of the impact of the COVID-19 outbreak on the ecological domain, the energy sector, society and the economy and investigate the global preventive measures taken to reduce the transmission of COVID-19. This analysis unpacks the key responses to COVID-19, the efficacy of current initiatives, and summarises the lessons learnt as an update on the information available to authorities, business and industry. This review found that a 72-hour delay in the collection and disposal of waste from infected households and quarantine facilities is crucial to controlling the spread of the virus. Broad sector by sector plans for socio-economic growth as well as a robust entrepreneurship-friendly economy is needed for the business to be sustainable at the peak of the pandemic. The socio-economic crisis has reshaped investment in energy and affected the energy sector significantly with most investment activity facing disruption due to mobility restrictions. Delays in energy projects are expected to create uncertainty in the years ahead. This report will benefit governments, leaders, energy firms and customers in addressing a pandemic-like situation in the future.

1. Introduction

The newly identified infectious coronavirus (SARS-CoV-2) was discovered in Wuhan and has spread rapidly since December 2019 within China and to other countries around the globe ( Zhou et al., 2020 ; Kabir et al., 2020 ). The source of SARS-CoV-2 is still unclear ( Gorbalenya et al., 2020 ). Fig. 1 demonstrates the initial timeline of the development of SARS-CoV-2 ( Yan et al., 2020 ). The COVID-19 pandemic has posed significant challenges to global safety in public health ( Wang et al., 2020 ). On 31 st January 2020, the World Health Organization (WHO), due to growing fears about the rapid spread of coronavirus, announced a global epidemic and on 11 th March, the disease was recognised as a pandemic ( Chowdhury et al., 2021 ). COVID-19 clinical trials indicate that almost all patients admitted to hospital have trouble breathing and pneumonia-like symptoms ( Holshue et al., 2020 ). Clinical diagnosis has identified that COVID-19 (disease caused by SARS-CoV-2) patients have similar indications to other coronavirus affected patients, e.g. Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) ( Wang and Su, 2020 ). The initial indication of a COVID-19 infection is coughing, fever, and short breath, and in the later stages, it can damage the kidney, cause pneumonia, and unexpected death ( Mofijur et al., 2020 ). The vulnerability of the elderly (>80 years of age) is high, with a fatality rate of ~22% of cases infected by COVID-19 ( Abdullah et al., 2020 ). The total number of confirmed COVID-19 cases has reached over 33 million as of 29 th September 2020, with more than 213 countries and regions affected by the pandemic ( Worldometer, 2020 ). Over 1,003,569 people have already passed away ( Worldometer, 2020 ) due to COVID-19. Most countries are currently trying to combat the virus spread by screening for COVID-19 in large numbers and maintaining social distancing policies with an emphasis on the health of human beings.

The initial stage development timeline for COVID-19 ( Yan et al., 2020 ).

Fig. 2 shows infections and replication cycle of the coronavirus. In extreme cases, the lungs are the most severely damaged organ of a SARS-CoV-2 infected person (host). The alveoli are porous cup-formed small cavities located in the structure of the lungs where the gas exchange of the breathing process take place. The most common cells on the alveoli are the type II cells.

Infections and replication cycle of the coronavirus ( Acter et al., 2020 ).

It has been reported that travel restrictions play a significant role in controlling the initial spread of COVID-19 ( Chinazzi et al., 2020 ; Aldila et al., 2020 ; Beck and Hensher, 2020 ; Bruinen de Bruin et al., 2020 ; de Haas et al., 2020 ). It has been reported that staying at home is most useful in controlling both the initial and last phase of infectious diseases ( de Haas et al., 2020 ; Cohen, 2020 , Pirouz et al., 2020 ). However, since the start of the COVID-19 pandemic, quarantines, entry bans, as well as other limitations have been implemented for citizens in or recent travellers to several countries in the most affected areas ( Sohrabi et al., 2020 ). Also, most of the industries were shutdown to lower mobility. A potential benefit of these measures is the reduction of pollution by the industrial and transportation sector, improving urban sustainability ( Jiang et al., 2021 ). Fig. 3 shows the global responses to lower the impact of the COVID-19 outbreak. There have been negative economic and social implications due to restrictions and decreased travel readiness worldwide ( Leal Filho et al., 2020 ). A fall in the volume of business activity and international events and an increase in online measures could have a long-term impact. The status of global transport and air activity as a result of the COVID-19 pandemic is shown in Fig. 4 ( International Energy Agency (IEA), 2020 ). By March 2020, the average global road haulage activity in regions with lockdowns had declined to almost 50% of the 2019 standard. Air travel has almost completely stopped in certain regions with aviation activity decreasing by over 90% in some European countries. Air activity in China recovered slightly from a low in late February, with lockdown measures somewhat eased. Nevertheless, as lockdowns spread, by the end of Q1 2020, global aviation activity decreased by a staggering 60%.

Initial preventive measures to lower the COVID-19 outbreak ( Bruinen de Bruin et al., 2020 ).

Global transport and aviation activity in the first quarter of the year 2020 ( International Energy Agency (IEA), 2020 ).

The spread of COVID-19 continues to threaten the public health situation severely ( Chinazzi et al., 2020 ) and greatly affect the global economy. Labour displacement, business closures and stock crashes are just some of the impacts of this global lockdown during the pandemic. According to the International Monetary Fund (IMF), the effect of COVID-19 will result in a worldwide economic decline in 2020 and a decline in the economic growth to 3% ( International Monetary Fund (IMF) ). COVID-19 has a detrimental impact on economic growth due to two primary factors. In the beginning, the exponential growth of the global epidemic directly contributed to considerable confusion about instability in the financial and capital markets. Secondly, countries have strictly regulated human movement and transport to monitor the growth of the epidemic and significantly reduced economic activity, putting pressure on both consumer and productive economic activity.

Since the 1970s, the link between economic growth and pollution has been an important global concern. The assessment of energy and financial efficiency is usually connected to environmental pollution research. Green practices at a national level, the inclusion of renewable energy, regulatory pressure and the sustainable use of natural resources are associated with environmental sustainability ( Khan et al., 2020 ). One study has shown that environmental pollution increases with economic growth and vice versa ( Cai et al., 2020 ). The strict control over movement and business activity due to COVID-19 has led to an economic downturn, which is in turn, expected to reduce environmental pollution. This paper systematically assesses how the novel coronavirus has had a global effect on society, the energy sector and the environment. This study presents data compiled from the literature, news sources and reports (from February 2020 to July 2020) on the management steps implemented across the globe to control and reduce the impact of COVID-19. The study will offer guidelines for nations to assess the overall impact of COVID-19 in their countries.

2. Impact of COVID-19 on the environmental domain

2.1. waste generation.

The generation of different types of waste indirectly creates a number of environmental concerns ( Schanes et al., 2018 ). The home isolation and pop-up confinement services in countries that have experienced major impacts of COVID-19 are standard practise, as hospitals are given priority to the most serious cases. In some countries, hotels are being used to isolate travellers for at least two weeks on entry. In several countries, such quarantine measures have resulted in consumers increasing their domestic online shopping activity that has increased domestic waste. In addition, food bought online is packaged, so inorganic waste has also increased. Medical waste has also increased. For instance, Wuhan hospitals produced an average of 240 metric tonnes of medical waste during the outbreak compared to their previous average of fewer than 50 tonnes ( Zambrano-Monserrate et al., 2020 ). This unusual situation poses new and major obstacles in the implementation of waste collection services, thus creating a new challenge for waste collection and recycling groups. With the global adaptation to exponential behavioural and social shifts in the face of COVID-19 challenges, municipal services such as waste collection and management need to alter their operations to play an important role in reducing the spread of infectious diseases.

2.1.1. Lifespan of COVID-19 on different waste media

SARS-CoV-2′s transmission activity has major repercussions for waste services. SARS-CoV-2 attacks host cells with ACE2 proteins directly. ACE2 is a cell membrane-associated enzyme in the lungs, heart and kidneys. When all the resources in the host cell are infected and depleted, the viruses leave the cell in the so-called shedding cycle ( Nghiem et al., 2020 ). Clinical and virological evidence suggests that the elimination of the SARS-CoV-2 virus is most relevant early on, right before and within a couple of days of the onset of the illness ( AEMO, 2020 ). Fomites are known as major vectors for the replication of other infectious viruses during the outbreak ( Park et al., 2015 ). Evidence from SARS-CoV-2 and other coronaviruses show that they remain effective for up to a few days in the atmosphere and on a variety of surfaces ( Fig. 5 ). The survival time of SARS-CoV-2 on hard and plastic surfaces is up to three days indicating that waste materials from COVID-19 patients may contain coronavirus and be a source of infection spread ( Chin et al., 2020 ). During the early stages of this epidemic, updated waste disposal methods to tackle COVID-19 were not implemented on the broader community. The concept of clinical waste essentially also applies to waste from contaminated homes and quarantine facilities. Throughout this pandemic, huge volumes of domestic and hospital waste, particularly plastic waste, has been generated. This has already impeded current efforts to reduce plastic waste and decrease its disposal in the environment. More effort should be made to find alternatives to heavily used plastics.

The lifespan of SARS-CoV-2 on different media ( Chin et al., 2020 ; van Doremalen et al.; 2020 ; Ye et al., 2016 )

2.1.2. Waste recycling service

COVID-19 has already had significant effects on waste recycling. Initially, as the outbreak spread and lockdowns were implemented in several countries, both public authorities and municipal waste management officials had to adjust to the situation quickly. Waste disposal has also been a major environmental problem for all technologically advanced nations, as no clear information was available about the retention time of SARS-CoV-2 ( Liu et al., 2020 ). Recycling is a growing and efficient means of pollution control, saving energy and conserving natural resources ( Ma et al., 2019 ). Recycling projects in various cities have been put on hold due to the pandemic, with officials worried about the possibility of COVID-19 spreading to recycling centres. Waste management has been limited in affected European countries. For example, Italy prohibited the sorting of waste by infected citizens. Extensive waste management during the pandemic is incredibly difficult because of the scattered nature of the cases and the individuals affected. The value of implementing best management practises for waste handling and hygiene to minimise employee exposure to potentially hazardous waste, should be highlighted at this time. Considering the possible role of the environment in the spread of SARS-CoV-2 ( Qu et al., 2020 ), the processing of both household and quarantine facility waste is a crucial point of control. Association of Cities and Regions for sustainable Resource management (ACR+) has reported on the provision of separate collection services to COVID-19 contaminated households and quarantine facilities to protect frontline waste workers in Europe, as shown in Fig. 6 . ACR+ also suggests a 72-hour delay in waste disposal (the possible lifespan of COVID-19 in the environment) ( Nghiem et al., 2020 ). Moreover, the collected waste should be immediately transported to waste incinerators or sites without segregation.

Recommended waste management during COVID-19 ( ACR+ 2020 ).

2.2. NO 2 emissions

Without the global pandemic, we had naively anticipated that in 2020 global emissions would rise by around 1% on a five-year basis. Instead, the sharp decline in economic activity in response to the current crisis will most probably lead to a modest drop in global greenhouse emissions. The European Space Agency (ESA), with its head office in Paris, France, is an intergovernmental body made up of 22 European countries committed to exploring the international space. To monitor air pollution in the atmosphere, the ESA uses the Copernicus Sentinel-5P Satellite. In addition to the compound contents measurement, the Copernicus Sentinel-5P troposphere monitor (TROPOMI) and other specified precision equipment measure ozone content, sulphur dioxide, carbon monoxide, and methane. Table 1 shows NO 2 emissions data acquisition by ESA using Sentinel-5P across different regions of Europe ( Financial Times, 2020 ).

NO 2 emissions data acquisition by ESA using Sentinel-5P across different regions of Europe ( Financial Times, 2020 ).

Country	Initial data	Final data	% reduction
Europe	March 2019	March 2020	Up to 30%
Italy	March 2019	March 2020	Up to 30%
France	March 2019	March 2020	Up to 30%
Spain	March 2019	March 2020	Up to 30%
UK	January 2020	March 2020	Up to 36%

Burning fossil fuels, such as coal, oil, gas and other fuels, is the source of atmospheric nitrogen dioxide ( Munawer, 2018 ). The bulk of the NO 2 in cities, however, comes from emissions from motor vehicles (approximately 80%). Other NO 2 sources include petroleum and metal refining, coal-fired electricity, other manufacturing and food processing industries. Some NO 2 is naturally produced by lightning in the atmosphere and from the soil, water, and plants, which, taken together, constitutes not even 1% of the total NO 2 found in the air of our localities. Due to pollution variations as well as changes in weather conditions, the levels of the NO 2 in our atmosphere differ widely every day. Anthropogenic pollution is estimated to contain around 53 million tonnes of NO 2 annually. Nitrogen dioxide, together with nitrogen oxide (NO), are considered the major components of oxides of nitrogen (NOx) ( M Palash et al., 2013 ; Fattah et al., 2013 ). NO, and NO 2 are susceptible to other chemicals and form acid rain that is toxic to the environment ( Mofijur et al., 2013 ; Ashraful et al., 2014 ), WHO lists NO 2 as one of the six typical air contaminants in the atmosphere. For this reason, the amount of NO 2 in the atmosphere is used as a precise measure for determining whether the COVID-19 outbreak affects environmental pollution.

NO 2 is an irritating reddish-brown gas with an unpleasant smell, and when cooled or compressed, it becomes a yellowish-brown liquid ( Wang and Su, 2020 ). NO 2 inflames the lung linings and can decrease lung infection immunity. High levels of NO 2 in the air we breathe can corrode our body's lung tissues . Nitrogen dioxide is a problematic air pollutant because it leads to brown photochemical smog formation, which can have significant impacts on human health ( Huang et al., 2020 ). Brief exposure to high concentrations of NO 2 can lead to respiratory symptoms such as coughing, wheezing, bronchitis, flu, etc., and aggravate respiratory illnesses such as asthma. Increased NO 2 levels can have major effects on individuals with asthma, sometimes leading to frequent and intense attacks ( Munawer, 2018 ). Asthmatic children and older individuals with cardiac illness are most vulnerable in this regard. However, its main drawback is that it produces two of the most harmful air pollutants, ozone and airborne particles. Ozone gas affects our lungs and the crops we eat.

2.2.1. NO₂ emissions across different countries

According to the ESA ( European Space Agency (ESA), 2020 ), average levels of NO 2 declined by 40% between 13 th March 2020 to 13 th April 2020. The reduction was 55% compared to the same period in 2019. Fig. 7 compares the 2019-2020 NO 2 concentration ( European Space Agency (ESA), 2020 ). The displayed satellite image was captured with the TROPOMI by ESA satellite Sentinel-5P. The percentage reductions in average NO 2 emissions in European countries during the COVID-19 outbreak from 1 st April to 30 th April 2020 can be seen in Fig. 8 ( Myllyvirta, 2020 ). Portugal, Spain, Norway, Croatia, France, Italy, and Finland are the countries that experienced the largest decrease in NO 2 levels, with 58%, 48%, 47%, 43% and 41%, respectively.

Comparison of the NO 2 concentration between 2019 and 2020 in Europe ( European Space Agency (ESA), 2020 ).

Changes in average NO 2 emission in different countries ( Myllyvirta, 2020 ).

The average 10-day animation of NO 2 emissions throughout Europe (from 1 st January to 11 th March 2020), demonstrated the environmental impact of Italy's economic downturn, see Fig. 9 ( European Space Agency (ESA), 2020 ). In the recent four weeks (Last week of February 2020 to the third week of March 2020) the average concentration of NO 2 in Milan, Italy, has been at least 24% less than the previous four weeks. In the week of 16 – 22 March, the average concentration was 21% lower than in 2019 for the same week. Over the last four weeks of January 2020, NO 2 emissions in Bergamo city has been gradually declining. During the week of 16–22 March, the average concentration was 47% less than in 2019. In Rome, NO 2 rates were 26–35% lower than average in the last four weeks (third week of January 2020 to the third week of February 2020) than they were during the same week of 2019 ( Atmosphere Monitoring Service, 2020 ).

Changes of NO 2 emission (a) over entire Italy (b) capital city (c) other cities ( European Space Agency (ESA), 2020 ; Atmosphere Monitoring Service, 2020 ).

Fig. 10 shows a comparison of NO 2 volumes in Spain in March 2019 and 2020. As per ( European Space Agency (ESA), 2020 ), Spain's NO 2 pollutants decreased by up to 20–30% due to lockdown, particularly across big cities like Madrid, Barcelona, and Seville. ESA Sentinel-5P captured the satellite image using TROPOMI. Satellite images of the 10 days between 14 th and 25 th March 2020 show that NO 2 tropospheric concentration in the areas of Madrid, Barcelona, Valencia, and Murcia ranges from 0–90 mg/m 3 . The NO 2 tropospheric concentration for Seville is almost 0 mg/m 3 for the same time. For March 2019, the average NO 2 tropospheric concentration for the Madrid area was between 90 and 160 mg/m 3 . At the same time, the range of NO 2 tropospheric concentration for Barcelona, Valencia, and Seville area was between 90–140 mg/m 3 , 90-130 mg/m 3 , and 30–50 mg/m 3 , respectively.

Comparison between before and after lockdown NO 2 emissions in Spain ( European Space Agency (ESA), 2020 ).

Fig. 11 shows the reduction in the amount of NO 2 emissions in France in March 2019 and 2020 ( European Space Agency (ESA), 2020 ). In France, levels of NO 2 have been reduced by 20% to 30%. The ESA Sentinel-5P satellite image was captured with the TROPOMI. In Paris and other major cities, the emission levels of NO 2 considerably lowered due to lockdown. The three major areas of France where NO 2 tropospheric concentration was significant are Paris, Lyon, Marseille and their surroundings. Satellite images of the ten days between 14 th and 25 th March 2020 show that NO 2 tropospheric concentration of the Paris, Lyon, Marseille areas ranges 30–90 mg/m 3 , 20–40 mg/m 3 and 40–80 mg/m 3 , respectively. For March 2019, the average NO 2 tropospheric concentration for the same areas was reported as 100–160 mg/m 3 , 30–60 mg/m 3, and 90–140 mg/m 3 , respectively.

Comparison of NO 2 emissions in France before and after lockdown ( European Space Agency (ESA), 2020 ).

Various industries across the UK have been affected by COVID-19, which has influenced air contamination. As shown in Fig. 12 , there were notable drops in the country's NO 2 emissions on the first day of quarantine ( Khoo, 2020 ). Edinburgh showed the most significant reduction. The average NO 2 emissions on 26 th March 2020, were 28 μg/m 3 while on the same day of 2019, this was 74 μg/m 3 ( Khoo, 2020 ). The second biggest reduction was observed in London Westminster where emissions reduced from 58 µg/m 3 to 30 µg/m 3 . Not all cities have seen such a significant decrease, with daily air pollution reducing by 7 μg/m 3 compared to the previous year in Manchester Piccadilly, for example ( Statista, 2020 ).

(a) Changes in NO 2 emissions in the UK during lockdown ( European Space Agency (ESA), 2020 ); (b) comparison of NO 2 emissions in 2019 and 2020 ( Khoo, 2020 ).

2.3. PM emission

The term particulate matter, referred to as PM, is used to identify tiny airborne particles. PM forms in the atmosphere when pollutants chemically react with each other. Particles include pollution, dirt, soot, smoke, and droplets. Pollutants emitted from vehicles, factories, building sites, tilled areas, unpaved roads and the burning of fossil fuels also contribute to PM in the air ( Baensch-Baltruschat et al., 2020 ). Grilling food (by burning leaves or gas grills), smoking cigarettes, and burning wood on a fireplace or stove also contribute to PM. The aerodynamic diameter is considered a simple way to describe PM's particle size as these particles occur in various shapes and densities. Particulates are usually divided into two categories, namely, PM 10 that are inhalable particles with a diameter of 10 μm or less and PM 2.5 which are fine inhalable particle with a diameter of 2.5 μm or less. PM 2.5 exposure causes relatively severe health problems such as non-fatal heart attacks, heartbeat irregularity, increased asthma, reduced lung function, heightened respiratory symptoms, and premature death ( Weitekamp et al., 2020 ).

PM 2.5 also poses a threat to the environment, including lower visibility (haze) in many parts of the globe. Particulates can be transported long distances then settle on the ground or in water sources. In these contexts and as a function of the chemical composition, PM 2.5 may cause acidity in lakes and stream water, alter the nutrient balance in coastal waters and basins, deplete soil nutrients and damage crops on farms, affect the biodiversity in the ecosystem, and contribute to acid rain. This settling of PM, together with acid rain, can also stain and destroy stones and other materials such as statues and monuments, which include valuable cultural artefacts ( Awad et al., 2020 ).

2.3.1. PM emission in different countries

Due to the COVID-19 outbreak, PM emission in most countries has been reduced ( Chatterjee et al., 2020 ; Ghahremanloo et al., 2021 ; Gualtieri et al., 2020 ; Sharifi and Khavarian-Garmsir, 2020 ; Srivastava, 2020 ). Fig. 13 shows the impact of COVID19 on PM emission in a number of some countries around the world ( Myllyvirta, 2020 ). The largest reductions in PM pollution took place in Portugal, with 55%, followed by Norway, Sweden, and Poland with reductions of 32%, 30%, and 28%, respectively. Spain, Poland, and Finland recorded PM emission reductions of 19%, 17% and 16%, respectively. Both Romania and Croatia recorded no changes in PM level, with Switzerland and Hungary recording about a 3% increase in PM emission.

Reduction of PM emission in different countries ( Myllyvirta, 2020 ).

PM emissions have been significantly reduced during the epidemic in most regions of Italy. Fig. 14 illustrates the changes in COVID-19 containment emissions before and after a lockdown in major cities in Italy. According to a recent study by Sicard et al. ( Sicard et al., 2020 ), lockdown interventions have had a greater effect on PM emission. They found that confinement measures reduce PM 10 emissions in all major cities by “around 30% to 53%” and “around 35% to 56%”.

Comparison of PM emission in Italy (a) PM 2.5 emission (b) Changes of PM 2.5 emission (c) PM 10 emission (d) Changes of PM 10 emission ( Sicard et al., 2020 ).

2.4. Noise emission

Noise is characterised as an undesirable sound that may be produced from different activities, e.g. transit by engine vehicles and high volume music. Noise can cause health problems and alter the natural condition of ecosystems. It is among the most significant sources of disruption in people and the environment ( Zambrano-Monserrate and Ruano, 2019 ). The European Environment Agency (EEA) states that traffic noise is a serious environmental problem that negatively affects the health and security of millions of citizens in Europe. The consequences of long-term exposure to noise include sleep disorders, adverse effects on the heart and metabolic systems, and cognitive impairment in children. The EEA estimates that noise pollution contributes to 48,000 new cases of heart disease and 12,000 early deaths per year. They also reported chronic high irritation for 22 million people and a chronic high level of sleep disorder for 6.5 million people ( Lillywhite, 2020 ).

Most governments have imposed quarantine measures that require people to spend much more time at home. This has considerably reduced the use of private and public transport. Commercial activities have almost completely stopped. In most cities in the world, these changes have caused a significant decline in noise levels. This was followed by a significant decline in pollution from contaminants and greenhouse gas emissions. Noise pollution from sources like road, rail or air transport has been linked to economic activity. Consequently, we anticipate that the levels of transport noise will decrease significantly due to the decreased demand for mobility in the short term ( Ro, 2020 ).

For example, it was obvious that environmental noise in Italy was reduced after 8 th March 2020 (the lockdown start date) due to a halt in commercial and recreational activities. A seismograph facility in Lombardy city in Italy that was severely affected by the COVID-19 pandemic indicated how the quarantine measures reduce both traffic and noise emissions. The comparison of the 24-hour seismic noise data before and after the lockdown period indicates a considerable drop in environmental noise in Italy ( Bressan, 2020 ).

3. Impact of COVID-19 on the socio-economic domain

COVID-19 has created a global health crisis where countless people are dying, human suffering is spreading, and people's lives are being upended ( Nicola et al., 2020 ). It is not only just a health crisis but also a social and economic crisis, both of which are fundamental to sustainable development ( Pirouz et al., 2020 ). On 11 th March 2020, when WHO declared a global pandemic, 118,000 reported cases spanning 114 countries with over 4,000 fatalities had been reported. It took 67 days from the first reported case to reach 100,000 cases, 11 days for the second 100,000, and just four days for the third ( United Nations Development Programme (UNDP), 2020 ). This has overwhelmed the health systems of even the richest countries with doctors being forced to make the painful decision of who lives and who dies. The COVID-19 pandemic has pushed the world into uncertainty and countries do not have a clear exit strategy in the absence of a vaccine. This pandemic has affected all segments of society. However, it is particularly damaging to vulnerable social groups, including people living in poverty, older persons, persons with disabilities, youths, indigenous people and ethnic minorities. People with no home or shelter such as refugees, migrants, or displaced persons will suffer disproportionately, both during the pandemic and in its aftermath. This might occur in multiple ways, such as experiencing limited movement, fewer employment opportunities, increased xenophobia, etc. The social crisis created by the COVID-19 pandemic may also increase inequality, discrimination and medium and long-term unemployment if not properly addressed by appropriate policies.

The protection measures taken to save lives are severely affecting economies all over the world. As discussed previously, the key protection measure adopted universally is the lockdown, which has forced people to work from home wherever possible. Workplace closures have disrupted supply chains and lowered productivity. In many instances, governments have closed borders to contain the spread. Other measures such as travel bans and the prohibition of sporting events and other mass gatherings are also in place. In addition, measures such as discouraging the use of public transport and public spaces, for example, restaurants, shopping centres and public attractions are also in place in many parts of the world. The situation is particularly dire in hospitality-related sectors and the global travel industry, including airlines, cruise companies, casinos and hotels which are facing a reduction in business activity of more than 90% ( Fernandes, 2020 ). The businesses that rely on social interactions like entertainment and tourism are suffering severely, and millions of people have lost their jobs. Layoffs, declines in personal income, and heightened uncertainty have made people spend less, triggering further business closures and job losses ( Ghosh, 2020 ).

A key performance indicator of economic health is Gross Domestic Product (GDP), typically calculated on a quarterly or annual basis. IMF provides a GDP growth estimate per quarter based on global economic developments during the near and medium-term. According to its estimate, the global economy is projected to contract sharply by 3% in 2020, which is much worse than the 2008 global financial crisis ( International Monetary Fund (IMF), 2020 ). The growth forecast was marked down by 6% in the April 2020 World Economic Outlook (WEO) compared to that of the October 2019 WEO and January 2020 WEO. Most economies in the advanced economy group are expected to contract in 2020, including the US, Japan, the UK, Germany, France, Italy and Spain by 5.9%, 5.4%, 6.5%, 7.0%, 7.2%, 9.1%, and 8.0% respectively. Fig. 15 a shows the effect of COVID-19 on the GDP of different countries around the globe. On the other hand, economies of emerging market and developing economies, excluding China, are projected to contract by only 1.0% in 2020. The economic recovery in 2021 will depend on the gradual rolling back of containment efforts in the latter part of 2020 that will restore consumer and investor confidence. According to the April 2020 WEO, the level of GDP at the end of 2021 in both advanced and emerging market and developing economies is expected to remain below the pre-virus baseline (January 2020 WEO Update), as shown in Fig. 15 b.

(a) Quarterly World GDP. 2019:Q1 =100, dashed line indicates estimates from January 2020 WEO; (b) GDP fall due to lockdown in selected countries.

A particular example of a country hardest hit by COVID-19 is Italy. During the early days of March, the Italian government imposed quarantine orders in major cities that locked down more than seventeen million people ( Andrews, 2020 ). The mobility index data by Google for Italy shows there has been a significant reduction in mobility (and therefore economic activity) across various facets of life. The reported decline of mobility in retail and recreation, grocery and pharmacy, transit stations and workplaces were 35%, 11%, 45% and 34% respectively ( Rubino, 2020 ). The Italian economy suffered great financial damage from the pandemic. The tourism, and hospitality sectors were among those most severely affected by foreign countries prohibiting travel to and from Italy, and by the government's national lockdowns in early March ( Brunton, 2020 ). A March 2020 study in Italy showed that about 99% of the companies in the housing and utility sector said the epidemic had affected their industry. In addition, transport and storage was the second most affected sector. Around 83% of companies operating in this sector said that their activities had been affected by the coronavirus ( Statista, 2020 ) pandemic. In April 2020, Italian Minister Roberto Gualtieri estimated a 6% reduction in the GDP for the year 2020 ( Bertacche et al., 2020 ). The government of Italy stopped all unnecessary companies, industries and economic activities on 21 st March 2020. Therefore The Economist estimates a 7% fall in GDP in 2020 ( Horowitz, 2020 ). The Economist predicted that the Italian debt-to-GDP ratio would grow from 130% to 180% by the end of 2020 ( Brunton, 2020 ) and it is also assumed that Italy will have difficulty repaying its debt ( Bertacche et al., 2020 ).

4. Impact of COVID-19 on the energy domain

COVID-19 has not only impacted health, society and the economy but it has also had a strong impact on the energy sector ( Chakraborty and Maity, 2020 ; Abu-Rayash and Dincer, 2020 ). World energy demand fell by 3.8% in the first quarter (Q1) of 2020 compared with Q1 2019. In Q1 of 2020, the global coal market was heavily impacted by both weather conditions and the downturn in economic activity resulting in an almost 8% fall compared to Q1 2019. The fall was primarily in the electricity sector as a result of substantial declines in demand (-2.5%) and competitive advantages from predominantly low-cost natural gas. The market for global oil has plummeted by almost 5%. Travel bans, border closures, and changes in work routines significantly decreased the demand for the use of personal vehicles and air transport. Thus rising global economic activity slowed down the use of fuel for transportation ( Madurai Elavarasan et al., 2020 ). In Q1 2020, the output from nuclear energy plants decreased worldwide, especially in Europe and the US, as they adjusted for lower levels of demand. Demand for natural gas dropped significantly, by approximately 2% in Q1 2020, with the biggest declines in China, Europe, and the United States. In the Q1 2020, the need for renewable energy grew by around 1.5%, driven in recent years by the increasing output of new wind and solar plants. Renewable energy sources substantially increased in the electricity generation mix, with record hourly renewable energy shares in Belgium, Italy, Germany, Hungary, and East America. The share of renewable energy sources in the electricity generation mix has increased. Table 2 shows the effect of COVID-19 outbreak on the energy demand around the world.

Impact of COVID-19 on global energy sector ( AEMO, 2020 ; CIS Editorial, 2020 ; Eurelectric, 2020 ; Livemint, 2020 ; Renewable Energy World, 2020 ; S&P Global, 2020 ; Madurai Elavarasan et al., 2020 ).

Country	Lockdown start	Lockdown end	Energy demand
Australia	23 March 2020	15 May 2020 (Stage 1, for NSW)	NSW: Weekday: 8%–10%↓ (morning) 6%–8%↓ (afternoon) Weekend: 5%–6%↓ (most of the day)
Belgium	18 March 2020	19 April 2020	Substantial ↓ in the industrial and commercial load of 70%
China	23 January 2020	8 April 2020	8%↓ (Jan & Feb compared to the same time in 2019)
France	17 March 2020	11 May 2020	6%–12%↓ (electricity demand)
Germany	20 March 2020	20 April 2020	4%–6% ↓ (electricity demand)
India	25 March 2020	4 May 2020	30%↓
Italy	9 March 2020	4 May 2020	10.1%↓ (March) 22%↓(from 22 March)
Portugal	13 March 2020	11 April 2020	Overall energy demand ↓
Singapore	7 April 2020	1 June 2020	8%–9%↓
Spain	14 March 2020	25 April 2020	3%↓ (March) 20%↓ (April), 72%↑ (PV generation)
Netherlands	16 March 2020	28 April 2020	Overall energy demand ↓
UK	24 March 2020	11 May 2020	10%↓ (after 23 March)
US	20 March 2020	29 April 2020	4.2% ↓ (retail sales of electricity)

Different areas have implemented lockdown of various duration. Therefore, regional energy demand depends on when lockdowns were introduced and how lockdowns influence demand in each country. In Korea and Japan, the average impact on demand is reduced to less than 10%, with lower restrictions. In China, where the first COVID-19 confinement measures were introduced, not all regions faced equally stringent constraints. Nevertheless, virus control initiatives have resulted in a decline of up to 15% in weekly energy demand across China. In Europe, moderate to complete lockdowns were more radical. On average, a 17% reduction in weekly demand was experienced during temporary confinement periods. India's complete lockdown has cut energy requirements by approximately 30%, which indicates yearly energy needs are lowered by 0.6% for each incremental lockdown week ( International Energy Agency (IEA) 2020 ).

The International Energy Agency (IEA) has predicted an annual average decline in oil production of 9% in 2020, reflecting a return to 2012 levels. Broadly, as electricity demand has decreased by about 5% throughout the year, coal production may fall by 8%, and the output of coal-fired electricity generation could fall by more than 10%. During the entire year, gas demand may fall far beyond Q1 2020 due to a downward trend in power and industrial applications. Nuclear energy demand will also decrease in response to reduced electricity demand. The demand for renewable energies should grow due to low production costs and the choice of access to many power systems. Khan et al. (2020) reported that international trade is significantly and positively dependent on renewable energy. In addition, sustainable growth can be facilitated through the consumption of renewable energy which improves the environment, enhances national image globally and opens up international trade opportunities with environmentally friendly countries ( Khan et al., 2021 ). As such, policies that promote renewables can result in economic prosperity, create a better environment as well as meet critical goals for sustainable development ( Khan et al., 2020 ).

5. Preventive measures to control COVID-19 outbreak

COVID-19 is a major crisis needing an international response. Governments will ensure reliable information is provided to assist the public in combating this pandemic. Community health and infection control measures are urgently needed to reduce the damage done by COVID-19 and minimise the overall spread of the virus. Self-defence techniques include robust overall personal hygiene, face washing, refraining from touching the eyes, nose or mouth, maintaining physical distance and avoiding travel. In addition, different countries have already taken preventive measures, including the implementation of social distancing, medicine, forestation and a worldwide ban on wildlife trade. A significant aim of the community health system is to avoid SARS-CoV-2 transmission by limiting large gatherings. COVID-19 is transmitted by direct communication from individual to individual. Therefore, the key preventive technique is to limit mass gatherings. Table 3 shows the impact of lockdown measures on the recovery rate of COVID-19 infections. The baseline data for this table is the median value, for the corresponding day of the week, during the 5-week period 3 rd January to 6 th February 2020.

Mobility index report of different countries ( Ghosh, 2020 ; Johns Hopkins University (JHU), 2020 ; Worldometer, 2020 ).

Country	Total population	Mobility rate	Recovery rate	Total Cases	Total recovered
Argentina	45,195,774	-56%	42.63%	153,520	65,447
Australia	25,499,884	-41%	64.02%	13,948	8,929
Austria	9,006,398	-100%	89.11%	20,338	18,124
Belgium	11,589,623	-105%	26.68%	65,199	17,394
Brazil	212,559,417	-48%	67.81%	2,348,200	1,592,281
Canada	37,742,154	-67%	87.34%	113,206	98,873
Chile	19,116,201	-110%	91.91%	341,304	313,696
Colombia	50,882,891	-73%	48.76%	233,541	113,864
Czech Republic	10,708,981	-29%	62.48%	15,081	9,422
Denmark	5,792,202	-93%	91.83%	13,438	12,340
Finland	5,540,720	-93%	93.67%	7,388	6,920
France	65,273,511	-100%	44.77%	180,528	80,815
Germany	83,783,942	-99%	92.44%	205,968	190,400
Greece	10,423,054	-32%	33.23%	4,135	1,374
Hong Kong	7,496,981	-10%	59.29%	2,373	1,407
Hungary	9,660,351	-49%	75.14%	4,424	3,324
India	1,380,004,385	-65%	63.49%	1,339,176	850,303
Indonesia	273,523,615	-77%	56.90%	97,286	55,354
Ireland	4,937,786	-79%	90.40%	25,845	23,364
Israel	8,655,535	-31%	45.06%	59,475	26,797
Italy	60,461,826	-52%	80.70%	245,590	198,192
Japan	126,476,461	-33%	76.29%	27,956	21,328
Malaysia	32,365,999	-53%	96.74%	8,884	8,594
Mexico	128,932,753	-69%	64.16%	378,285	242,692
Netherlands	17,134,872	-97%	11.65%	52,837	6,158
New Zealand	4,822,233	-21%	97.24%	1,556	1,513
Norway	5,421,241	-100%	95.40%	9,092	8,674
Philippines	109,581,078	-87%	32.84%	78,412	25,752
Poland	37,846,611	-36%	76.06%	42,622	32,419
Portugal	10,196,709	-65%	69.80%	49,692	34,687
Singapore	5,850,342	-105%	90.55%	49,888	45,172
South Africa	59,308,690	-74%	58.24%	421,996	245,771
South Korea	51,269,185	-4%	91.30%	14,092	12,866
Spain	46,754,778	-67%	47.07%	319,501	150,376
Switzerland	8,654,622	-101%	88.92%	34,302	30,500
Taiwan	23,816,775	4%	96.07%	458	440
Thailand	69,799,978	-36%	94.73%	3,282	3,109
USA	331,002,651	-56%	47.74%	4,248,759	2,028,361
UK	67,886,011	-82%	0.48%	297,914	1,427
Vietnam	97,338,579	15%	87.53%	417	365

As of today, no COVID-19 vaccine is available. Worldwide scientists are racing against time to develop the COVID-19 vaccine, and WHO is now monitoring more than 140 vaccine candidates. As of 29 th September 2020, about 122 candidates have been pre-clinically checked, i.e. determining whether an immune response is caused when administering the vaccine to animals ( Biorender, 2020 ). About 45 candidates are in stage I where tests on a small number of people are conducted to decide whether it is effective ( Biorender, 2020 ). About 29 candidates are in Phase II where hundreds of people are tested to assess additional health issues and doses ( Biorender, 2020 ). Only 14 candidates are currently in Phase III, where thousands of participants are taking a vaccine to assess any final safety concerns, especially with regard to side effects ( Biorender, 2020 ). 3 candidates are in Phase IV, where long-term effects of the vaccines on a larger population is observed ( Biorender, 2020 ). The first generation of COVID-19 vaccines is expected to gain approval by the end of 2020 or in early 2021 ( Peiris and Leung, 2020 ). It is anticipated that these vaccines will provide immunity to the population. These vaccines can also reduce the transmission of SARS-CoV-2 and lead to a resumption of a pre-COVID-19 normal. Table 4 shows the list of vaccines that have been passed in the pre-clinical stage. In addition, according to the COVID-19 vaccine and therapeutics tracker, there are 398 therapeutic drugs in development. Of these, 83 are in the pre-clinical phase, 100 in Phase I, 224 in Phase II, 119 in Phase III and 46 in Phase IV ( Biorender, 2020 ).

List of vaccines that have passed the pre-clinical stage ( Biorender, 2020 ).

Name	Organisation	Technology	Stage	Clinical Trial #
Oral Polio Vaccine	Bandim Health Project	Repurposed	Phase IV	NCT04445428
Bacille Calmette-Guerin	Multiple Organisations	Repurposed	Phase III/IV	NCT04328441
Measles-Mumps-Rubella Vaccine	Multiple Organisations	Repurposed	Phase III	NCT04357028
IMM-101	Multiple Organisations	Repurposed	Phase III	NCT04442048
BACMUNE (MV130)	Inmunotek S.L., BioClever 2005 S.L.	Repurposed	Phase III	NCT04452643
mRNA-1273	Multiple Organisations	RNA-based vaccine	Phase I/II/III	NCT04283461
CoronaVac	Sinovac Biotech Co., Butantan Institute	Inactivated virus	Phase I/II/III	NCT04352608
AZD1222 (ChAdOx1 nCoV-19)	Multiple Organisations	Non-replicating viral vector	Phase I/II/III	NCT04324606
NasoVAX	Altimmune, Inc.	Repurposed	Phase II	NCT04442230
LV-SMENP-DC	Shenzhen Geno-Immune Medical Institute	Modified APC	Phase I/II	NCT04276896
Ad5-nCoV	Multiple Organisations	Non-replicating viral vector	Phase I/II	NCT04313127
INO-4800	Multiple Organisations	DNA-based	Phase I/II	NCT04336410
Unnamed Inactive Vaccine - Wuhan	Wuhan Institute of Biological Products, Sinopharm	Inactivated virus	Phase I/II	ChiCTR2000031809
BBIBP-CorV	Beijing Institute of Biological Products, Sinopharm	Inactivated virus	Phase I/II	ChiCTR2000032459
BNT162 (a1, b1, b2, c2)	Biontech RNA Pharmaceuticals GmbH, Pfizer	RNA-based vaccine	Phase I/II	EudraCT 2020-001038-36
KBP-COVID-19	Kentucky BioProcessing, Inc.	Protein subunit	Phase I/II	NCT04473690
LUNAR-COV19 (ARCT-021)	Arcturus Therapeutics, Inc., Duke-NUS	RNA-based vaccine	Phase I/II	NCT04480957
COVAC 1	Imperial College London, Morningside Ventures	RNA-based vaccine	Phase I/II	IRAS-Number: 279315
AG0301-COVID19	AnGes, Inc.,Japan Agency for Medical Research and Development	DNA-based	Phase I/II	NCT04463472
V-SARS	Immunitor LLC	Inactivated virus	Phase I/II	NCT04380532
AV-COVID-19	Aivita Biomedical, Inc.	Modified APC	Phase I/II	NCT04386252
Unnamed Inactive Vaccine - Yunnan	Multiple Organisations	Inactivated virus	Phase I/II	NCT04412538
Gam-COVID-Vac	Gamaleya Research Institute of Epidemiology and Microbiology, Health Ministry of the Russian Federation, Acellena Contract Drug Research and Development	Non-replicating viral vector	Phase I/II	NCT04437875
AlloStim	Immunovative Therapies, Ltd., Mirror Biologics, Inc.	Other	Phase I/II	NCT04441047
GX-19	Genexine, Inc.	DNA-based	Phase I/II	NCT04445389
BBV152A, B, C	Bharat Biotech International Limited,Indian Council of Medical Research	Inactivated virus	Phase I/II	NCT04471519
bacTRL-Spike	Multiple Organisations	DNA-based	Phase I	NCT04334980
NVX-CoV2373	Novavax	Protein subunit	Phase I	NCT04368988
COVID-19/aAPC Vaccine	Shenzhen Geno-Immune Medical Institute	Modified APC	Phase I	NCT04299724
Unnamed VLP Vaccine	Medicago Inc.	Virus-like particle	Phase I	NCT04450004
CVnCoV	CureVac AG, Coalition for Epidemic Preparedness Innovations (CEPI)	RNA-based vaccine	Phase I	NCT04449276
SCB-2019	Clover Biopharmaceuticals	Protein subunit	Phase I	NCT04405908
COVAX-19	Multiple Organisations	Protein subunit	Phase I	NCT04428073

In addition to the above, forestation and a worldwide ban on wildlife trade can also play a significant role in reducing the spread of different viruses. More than 30% of the ground area is covered with forests. The imminent increase in population contributes to deforestation in agriculture or grazing for food, industries and property. The rise in ambient temperature, sea levels and extreme weather events affects not only the land and environment but also public health ( Ruscio et al., 2015 ; Arora and Mishra, 2020 ). Huge investment has been made into treatments, rehabilitation and medications to avoid the impact of this epidemic. However, it is important to focus on basic measures, e.g. forestation and wildlife protection. The COVID-19 infection was initially spread from the Seafood Market, Wuhan, China. Therefore, China temporarily banned wildlife markets in which animals are kept alive in small cages. It has been reported that 60% of transmittable diseases are animal-borne, 70% of which are estimated to have been borne by wild animals ( Chakraborty and Maity, 2020 ). Deforestation is also related to various kinds of diseases caused by birds, bats, etc. ( Afelt et al., 2018 ). For example, COVID-19 is a bat-borne disease that is transmitted to humans. Therefore, several scientists have advised various countries to ban wildlife trade indefinitely so that humans can be protected from new viruses and global pandemics like COVID-19.

6. Conclusion

In this article, comprehensive analyses of energy, environmental pollution, and socio-economic impacts in the context of health emergency events and the global responses to mitigate the effects of these events have been provided. COVID-19 is a worldwide pandemic that puts a stop to economic activity and poses a severe risk to overall wellbeing. The global socio-economic impact of COVID-19 includes higher unemployment and poverty rates, lower oil prices, altered education sectors, changes in the nature of work, lower GDPs and heightened risks to health care workers. Thus, social preparedness, as a collaboration between leaders, health care workers and researchers to foster meaningful partnerships and devise strategies to achieve socio-economic prosperity, is required to tackle future pandemic-like situations. The impact on the energy sector includes increased residential energy demand due to a reduction in mobility and a change in the nature of work. Lockdowns across the globe have restricted movement and have placed people primarily at home, which has, in turn, decreased industrial and commercial energy demand as well as waste generation. This reduction in demand has resulted in substantial decreases in NO 2, PM, and environmental noise emissions and as a consequence, a significant reduction in environmental pollution. Sustainable urban management that takes into account the positive benefits of ecological balance is vital to the decrease of viral infections and other diseases. Policies that promote sustainable development, ensuring cities can enforce recommended measures like social distancing and self-isolation will bring an overall benefit very quickly. The first generation of COVID-19 vaccines is expected to gain approval by the end of 2020 or in early 2021, which will provide immunity to the population. It is necessary to establish preventive epidemiological models to detect the occurrence of viruses like COVID-19 in advance. In addition, governments, policymakers, and stakeholders around the world need to take necessary steps, such as ensuring healthcare services for all citizens, supporting those who are working in frontline services and suffering significant financial impacts, ensuring social distancing, and focussing on building a sustainable future. It is also recommended that more investment is required in research and development to overcome this pandemic and prevent any similar crisis in the future.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Editor: Dr. Syed Abdul Rehman Khan

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IMAGES

COVID-19 measures have huge impact on young people's lives
UN/DESA Policy Brief #85: Impact of COVID-19: perspective from
Essay: COVID-19 pandemic impacts how we view, access mental health care
Allianz Partners
Impact of COVID-19 [Infographic]
Social and Wellbeing COVID-19 Information Hub

COMMENTS

Here's How the Coronavirus Pandemic Has Changed Our Lives
From lifestyle changes to better eating habits, people are using this time to get healthier in many areas. Since the pandemic started, nearly two-thirds of the survey's participants (62%) say ...
Impact of COVID-19 on people's livelihoods, their health and our food
Reading time: 3 min (864 words) The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an unprecedented challenge to public health, food systems and the world of work. The economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty ...
Insights into the impact on daily life of the COVID-19 pandemic and
1. Introduction. The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented changes in people's daily lives, with implications for mental health and well-being [1-4], both at the level of a given country's population, and when considering specific vulnerable groups [5-7].In order to mitigate the untoward impact of the pandemic (including lockdown) and support mental health ...
12 moving essays about life during coronavirus
Read these 12 moving essays about life during coronavirus. Artists, novelists, critics, and essayists are writing the first draft of history. A woman wearing a face mask in Miami. Alissa Wilkinson ...
Lifestyle and mental health disruptions during COVID-19
These results highlight the large impact of COVID-19 on both lifestyle and well-being and offer directions for interventions aimed at restoring mental health. Abstract Using a longitudinal dataset linking biometric and survey data from several cohorts of young adults before and during the COVID-19 pandemic ( N = 682 ), we document large ...
How the COVID-19 pandemic has changed Americans' personal lives
In many ways, the negatives clearly outweigh the positives - an unsurprising reaction to a pandemic that had killed more than 180,000 Americans at the time the survey was conducted. Across every major aspect of life mentioned in these responses, a larger share mentioned a negative impact than mentioned an unexpected upside.
How Is the Coronavirus Outbreak Affecting Your Life?
Feelings of isolation and loneliness can increase the likelihood of depression, high blood pressure, and death from heart disease. They can also affect the immune system's ability to fight ...
The Impact of the COVID-19 Pandemic on Lifestyle: How Young people have
Italy, the first European state to face the COVID-19 emergency, adopted early and stringent measures to contain transmission. On 30 January 2020, the national government declared a state of emergency; on 20 February, 11 municipalities were placed under quarantine, and by the beginning of March, the quarantine was extended to the whole national territory, restricting the movement of people ...
COVID-19 pandemic and its impact on social relationships and health
This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the ...
Impact of the COVID-19 Epidemic on Lifestyle Behaviors and Their
Previous studies have predominantly focused on the psychological impact of the COVID-19 epidemic, rather than lifestyle issues. For the first time, some perceived lifestyle changes after the outbreak of COVID-19 have been assessed, and the impact of such changes on mental health was also explored among the general population in Mainland China.
Impact of COVID-19 on Lifestyle, Personal Attitudes, and Mental Health
The current COVID-19 pandemic have affected our daily lifestyle, pressed us with fear of infection, and thereby changed life satisfaction and mental health. ... Impact of COVID-19 on Lifestyle, Personal Attitudes, and Mental Health Among Korean Medical Students: Network Analysis of Associated Patterns Front Psychiatry. 2021 Aug 18:12:702092 ...
Impact of COVID-19 on lifestyle-related behaviours- a cross-sectional
Impact of COVID-19 on lifestyle-related behavior: before and during COVID-19 comparison. The comparison of mean scores of lifestyle related behaviours before and during COVID-19 is shown in Table 3. There was a significant increase in routine consumption of meals at regular intervals during COVID-19 (0.3 [1.73], P < 0.001). There was ...
How to Write About Coronavirus in a College Essay
Writing About COVID-19 in College Essays. Experts say students should be honest and not limit themselves to merely their experiences with the pandemic. The global impact of COVID-19, the disease ...
Lifestyle changes during the first wave of the COVID-19 pandemic: a
Lifestyle changes during the COVID-19 pandemic. Although the majority of the surveyed population reported no significant change in their daily habits or intake of food/snacks since the COVID-19 outbreak in the Netherlands, we found substantial lifestyle changes in a considerable part of the population, both for the better and the worse (see Table 2). 14.0% of all respondents reported a ...
Frontiers
For more detailed profiling of the impact of COVID-19 on the medical students' daily living, ... Kim JW, Myung SJ, Yoon HB, Moon SH, Ryu H and Yim J-J (2021) Impact of COVID-19 on Lifestyle, Personal Attitudes, and Mental Health Among Korean Medical Students: Network Analysis of Associated Patterns. Front. Psychiatry 12:702092. doi: 10.3389 ...
The Impact of the COVID-19 Pandemic on Healthy Lifestyle Behaviors and
To assess the impact of the COVID-19 pandemic on healthy lifestyle behaviors and perceived mental and physical health of people with NCDs in our study, univariate logistic regressions were conducted. Results were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs), and variables having p -value ≤ 0.05 in the ...
PDF COVID-19 pandemic and its impact on social relationships and health
The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable,2 3 and the inequality of the health burden stark.4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain. The initial response to COVID-19 in the UK was
Effects of COVID-19 pandemic in daily life
Presently the impacts of COVID-19 in daily life are extensive and have far reaching consequences. These can be divided into various categories: Closure of places for entertainment such as movie and play theatres, sports clubs, gymnasiums, swimming pools, and so on. This COVID-19 has affected the sources of supply and effects the global economy.
'When Normal Life Stopped': College Essays Reflect a Turbulent Year
This year the Common App, the nation's most-used application, added a question inviting students to write about the impact of Covid-19 on their lives and educations.
Two Years In: How the Pandemic Changed Our Lives
The early days of the COVID-19 pandemic showed how Duke can respond in times of crisis. Read our story from March 2020 to see how your colleagues rose to the moment. Duke's COVID-19 Response. As some safety measures ease, COVID-19 has infected nearly 80 million Americans and left nearly 970,000 dead. As the pandemic raged with variants ...
Understanding the effects of Covid-19 through a life course lens
The Covid-19 pandemic is shaking fundamental assumptions about the human life course in societies around the world. In this essay, we draw on our collective expertise to illustrate how a life course perspective can make critical contributions to understanding the pandemic's effects on individuals, families, and populations.
Impact of COVID-19 on health-related quality of life in the general
The World Health Organization declared coronavirus disease of 2019 as an epidemic and public health emergency of international concern on January 30th, 2020. Different factors during a pandemic can contribute to low quality of life in the general population. Quality of life is considered multidimensional and subjective and is assessed by using patient reported outcome measures. The aim and ...
Paragraph Writing on Covid 19
Even though it was tough, people came together, supported each other, and adapted to the new normal. Covid-19 taught us a lot about resilience and the importance of healthcare. Persuasive Tone. Covid-19, caused by the novel coronavirus, has highlighted the urgent need for better healthcare systems and global cooperation.
PDF How COVID-19 Impacted My Professional and Personal Life
fe have changed immensely due to the COVID-19 pandemic. The most impacted aspects of work life are policies, service delivery, and work environment, especially with a new focus. n what we can do to deliver remote services efectively. The impacts to my personal life include my children's education, our shared work environment, and our health ...
Nutrients
Background: The COVID-19 lockdown represented an immense impact on human health, which was characterized by lifestyle and dietary changes, social distancing and isolation at home. Some evidence suggests that these consequences mainly affected women and altered relevant ongoing clinical trials. The aim of this study was to evaluate the status and changes in diet, physical activity (PA), sleep ...
The Psychosocial Impact of the COVID-19 Pandemic on Italian Families
Throughout the COVID-19 period, families were forced to stay indoors, adapting to online schooling, remote work, and virtual social engagements, inevitably altering the dynamics within households. There was a notable increase in mental health challenges in terms of anxiety and depression in children and adolescents. This study intended to explore the psychosocial effects of the COVID-19 ...
Exploring COVID-19's Impact On Undergraduate Nursing Students
The researchers aimed to assess the effects of the COVID-19 pandemic on nursing education through semi-structured interviews with undergraduate nursing students. The researchers explored themes related to online education, clinical placements, and mental health. Findings revealed that the sudden shift to online learning caused increased stress, and decreased confidence.
Readers respond to essays on long Covid, hypochondria, and more
F irst Opinion is STAT's platform for interesting, illuminating, and maybe even provocative articles about the life sciences writ large, written by biotech insiders, health care workers ...
Impact of COVID-19 and GP appointment availability on continuity of
Levene, L. S., et al. (2024). Ongoing Decline in Continuity With GPs in English General Practices: A Longitudinal Study Across the COVID-19 Pandemic. The Annals of Family Medicine.
Impact of COVID-19 on the social, economic, environmental and energy
1. Introduction. The newly identified infectious coronavirus (SARS-CoV-2) was discovered in Wuhan and has spread rapidly since December 2019 within China and to other countries around the globe (Zhou et al., 2020; Kabir et al., 2020).The source of SARS-CoV-2 is still unclear (Gorbalenya et al., 2020).Fig. 1 demonstrates the initial timeline of the development of SARS-CoV-2 (Yan et al., 2020).