thesis covid 19

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

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

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

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

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

Methodology

Research question.

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

Study design

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

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

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

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

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

Eligibility criteria

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

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

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

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

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

Information sources

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

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

Study selection

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

Data collection process

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

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

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

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

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

Quality assessment in individual reviews

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

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

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

Synthesis of results

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

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

Managing overlapping systematic reviews

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

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

PRISMA flow diagram

Characteristics of included reviews

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

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

Population and study designs

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

Systematic review findings

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

A meta-analysis of the prevalence of mortality

Clinical symptoms

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

A meta-analysis of the prevalence of fever

A meta-analysis of the prevalence of cough

A meta-analysis of the prevalence of dyspnea

A meta-analysis of the prevalence of fatigue or myalgia

A meta-analysis of the prevalence of headache

A meta-analysis of the prevalence of gastrointestinal disorders

A meta-analysis of the prevalence of sore throat

Diagnostic aspects

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

Therapeutic possibilities

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

Laboratory and radiological findings

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

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

Quality of evidence in individual systematic reviews

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

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

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Acknowledgments

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

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Israel Júnior Borges do Nascimento & Milena Soriano Marcolino

Medical College of Wisconsin, Milwaukee, WI, USA

Israel Júnior Borges do Nascimento

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

Dónal P. O’Mathúna

School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany

Thilo Caspar von Groote

Department of Sport and Health Science, Technische Universität München, Munich, Germany

Hebatullah Mohamed Abdulazeem

School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, Australia

Ishanka Weerasekara

Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Cochrane Croatia, University of Split, School of Medicine, Split, Croatia

Ana Marusic, Irena Zakarija-Grkovic & Tina Poklepovic Pericic

Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, 10000, Zagreb, Croatia

Livia Puljak

Cochrane Brazil, Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, Brazil

Vinicius Tassoni Civile & Alvaro Nagib Atallah

Yorkville University, Fredericton, New Brunswick, Canada

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

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Supplementary Information

Additional file 1: appendix 1..

Search strategies used in the study.

Additional file 2: Appendix 2.

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

Additional file 3: Appendix 3.

List of excluded studies, with reasons.

Additional file 4: Appendix 4.

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

Additional file 5: Appendix 5.

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

Additional file 6: Appendix 6.

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

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

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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
• Susan Patterson 1 ,
• Karen Maxwell 1 ,
• Carolyn Blake 1 ,
• http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
• Ruth Lewis 1 ,
• Mark McCann 1 ,
• Julie Riddell 1 ,
• Kathryn Skivington 1 ,
• Rachel Wilson-Lowe 1 ,
• http://orcid.org/0000-0002-4409-6601 Kirstin R Mitchell 2
• 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
• 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

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 nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

• inequalities

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study. Data sharing not applicable as no data sets generated or analysed for this essay.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/jech-2021-216690

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. 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 reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies

• Yibeltal Assefa   ORCID: orcid.org/0000-0003-2393-1492 1 ,
• Charles F. Gilks 1 ,
• Simon Reid 1 ,
• Remco van de Pas 2 ,
• Dereje Gedle Gete 1 &
• Wim Van Damme 2  

Globalization and Health volume  18 , Article number:  10 ( 2022 ) Cite this article

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The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of Public Health Emergencies of International Concern. As of 12 January 2022, there were over 314 million cases and over 5.5 million deaths notified since the start of the pandemic. The COVID-19 pandemic takes variable shapes and forms, in terms of cases and deaths, in different regions and countries of the world. The objective of this study is to analyse the variable expression of COVID-19 pandemic so that lessons can be learned towards an effective public health emergency response.

We conducted a mixed-methods study to understand the heterogeneity of cases and deaths due to the COVID-19 pandemic. Correlation analysis and scatter plot were employed for the quantitative data. We used Spearman’s correlation analysis to determine relationship strength between cases and deaths and socio-economic and health systems. We organized qualitative information from the literature and conducted a thematic analysis to recognize patterns of cases and deaths and explain the findings from the quantitative data.

We have found that regions and countries with high human development index have higher cases and deaths per million population due to COVID-19. This is due to international connectedness and mobility of their population related to trade and tourism, and their vulnerability related to older populations and higher rates of non-communicable diseases. We have also identified that the burden of the pandemic is also variable among high- and middle-income countries due to differences in the governance of the pandemic, fragmentation of health systems, and socio-economic inequities.

The COVID-19 pandemic demonstrates that every country remains vulnerable to public health emergencies. The aspiration towards a healthier and safer society requires that countries develop and implement a coherent and context-specific national strategy, improve governance of public health emergencies, build the capacity of their (public) health systems, minimize fragmentation, and tackle upstream structural issues, including socio-economic inequities. This is possible through a primary health care approach, which ensures provision of universal and equitable promotive, preventive and curative services, through whole-of-government and whole-of-society approaches.

The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of emerging infectious diseases that become Public Health Emergency of International Concern (PHEIC) [ 1 ]. The COVID-19 pandemic takes variable shapes and forms in how it affects communities in different regions and countries [ 2 , 3 ]. As of 12 January, 2022, there were over 314 million cases and over 5.5 million deaths notified around the globe since the start of the pandemic. The number of cases per million population ranged from 7410 in Africa to 131,730 in Europe while the number of deaths per million population ranged from 110 in Oceania to 2740 in South America. Case-fatality rates (CFRs) ranged from 0.3% in Oceania to 2.9% in South America [ 4 , 5 ]. Regions and countries with high human development index (HDI), which is a composite index of life expectancy, education, and per capita income indicators [ 6 ], are affected by COVID-19 more than regions with low HDI. North America and Europe together account for 55 and 51% of cases and deaths, respectively. Regions with high HDI are affected by COVID-19 despite their high universal health coverage index (UHCI) and Global Health Security index (GHSI) [ 7 ].

This seems to be a paradox (against the established knowledge that countries with weak (public) health systems capacity will have worse health outcomes) in that the countries with higher UHCI and GHSI have experienced higher burdens of COVID-19 [ 7 ]. The paradox can partially be explained by variations in testing algorithms, capacity for testing, and reporting across different countries. Countries with high HDI have health systems with a high testing capacity; the average testing rate per million population is less than 32, 000 in Africa and 160,000 in Asia while it is more than 800, 000 in HICs (Europe and North America). This enables HICs to identify more confirmed cases that will ostensibly increase the number of reported cases [ 3 ]. Nevertheless, these are insufficient to explain the stark differences between countries with high HDI and those with low HDI. Many countries with high HDI have a high testing rate and a higher proportion of symptomatic and severe cases, which are also associated with higher deaths and CFRs [ 7 ]. On the other hand, there are countries with high HDI that sustain a lower level of the epidemic than others with a similar high HDI. It is, therefore, vital to analyse the heterogeneity of the COVID-19 pandemic and explain why some countries with high HDI, UHCI and GHSI have the highest burden of COVID-19 while others are able to suppress their epidemics and mitigate its impacts.

The objective of this study was to analyse the COVID-19 pandemic and understand its variable expression with the intention to learn lessons for an effective and sustainable response to public health emergencies. We hypothesised that high levels of HDI, UHCI and GHSI are essential but not sufficient to prevent and control COVID-19.

We conducted an explanatory mixed-methods study to understand and explain the heterogeneity of the pandemic around the world. The study integrated quantitative and qualitative secondary data. The following steps were included in the research process: (i) collecting and analysing quantitative epidemiological data, (ii) conducting literature review of qualitative secondary data and (iii) evaluating countries’ pandemic responses to explain the variability in the COVID-19 epidemiological outcomes. The study then illuminated specific factors that were vital towards an effective and sustainable epidemic response.

We used the publicly available secondary data sources from Johns Hopkins University ( https://coronavirus.jhu.edu/data/new-cases ) for COVID-19 and UNDP 2020 HDI report ( http://hdr.undp.org/en/2019-report ) for HDI, demographic and epidemiologic variables. These are open data sources which are regularly updated and utilized by researchers, policy makers and funders. We performed a correlation analysis of the COVID-19 pandemic. We determined the association between COVID-19 cases, severity, deaths and CFRs at the 0.01 and 0.05 levels (2-tailed). We used Spearman’s correlation analysis, as there is no normal distribution of the variables [ 8 ].

The UHCI is calculated as the geometric mean of the coverage of essential services based on 17 tracer indicators from: (1) reproductive, maternal, newborn and child health; (2) infectious diseases; (3) non-communicable diseases; and, (4) service capacity and access and health security [ 9 ]. The GHSI is a composite measure to assess a country’s capability to prevent, detect, and respond to epidemics and pandemics [ 10 ].

We then conducted a document review to explain the epidemic patterns in different countries. Secondary data was obtained from peer-reviewed journals, reputable online news outlets, government reports and publications by public health-related associations, such as the WHO. To explain the variability of COVID-19 across countries, a list of 14 indicators was established to systematically assess country’s preparedness, actual pandemic response, and overall socioeconomic and demographic profile in the context of COVID-19. The indicators used in this study include: 1) Universal Health Coverage Index, 2) public health capacity, 3) Global Health Security Index, 4) International Health Regulation, 5) leadership, governance and coordination of response, 6) community mobilization and engagement, 7) communication, 8) testing, quarantines and social distancing, 9) medical services at primary health care facilities and hospitals, 10) multisectoral actions, 11) social protection services, 12) absolute and relative poverty status, 13) demography, and 14) burden of communicable and non-communicable diseases. These indicators are based on our previous studies and recommendation from the World Health Organization [ 3 , 4 ]. We conducted thematic analysis and synthesis to identify the factors that may explain the heterogeneity of the pandemic.

Heterogeneity of COVID-19 cases and deaths around the world: what can explain it?

Table  1 indicates that the pandemic of COVID-19 is heterogeneous around regions of the world. Figure  1 also shows that there is a strong and significant correlation between HDI and globalisation (with an increase in trade and tourism as proxy indicators) and a corresponding strong and significant correlation with COVID-19 burden.

Human development index and its correlates associated with COVID-19 in 189 countries*

Globalisation and pandemics interact in various ways, including through international trade and mobility, which can lead to multiple waves of infections [ 11 ]. In at least the first waves of the pandemic, countries with high import and export of consumer goods, food products and tourism have high number of cases, severe cases, deaths and CFRs. Countries with high HDI are at a higher risk of importing (and exporting) COVID-19 due to high mobility linked to trade and tourism, which are drivers of the economy. These may have led to multiple introductions of COVID-19 into these countries before border closures.

The COVID-19 pandemic was first identified in China, which is central to the global network of trade, from where it spread to all parts of the world, especially those countries with strong links with China [ 12 ]. The epidemic then spread to Europe. There is very strong regional dimension to manufacturing and trading, which could be facilitate the spread of the virus. China is the heart of ‘Factory Asia’; Italy is in the heart of ‘Factory Europe’; the United States is the heart of ‘Factory North America’; and Brazil is the heart of ‘Factory Latin America’ [ 13 ]. These are the countries most affected by COVID-19 during the first wave of the pandemic [ 2 , 3 , 14 ].

It is also important to note that two-third of the countries currently reporting more than a million cases are middle-income countries (MICs), which are not only major emerging market economies but also regional political powers, including the BRICS countries (Brazil, Russia, India and South Africa) [ 3 , 15 ]. These countries participate in the global economy, with business travellers and tourists. They also have good domestic transportation networks that facilitate the internal spread of the virus. The strategies that helped these countries to become emerging markets also put them at greater risk for importing and spreading COVID-19 due to their connectivity to the rest of the world.

In addition, countries with high HDI may be more significantly impacted by COVID-19 due to the higher proportion of the elderly and higher rates of non-communicable diseases. Figure 1 shows that there is a strong and significant correlation between HDI and demographic transition (high proportion of old-age population) and epidemiologic transition (high proportion of the population with non-communicable diseases). Countries with a higher proportion of people older than 65 years and NCDs (compared to communicable diseases) have higher burden of COVID-19 [ 16 , 17 , 18 , 19 , 20 ]. Evidence has consistently shown a higher risk of severe COVID-19 in older individuals and those with underlying health conditions [ 21 , 22 , 23 , 24 , 25 ]. CFR is age-dependent; it is highest in persons aged ≥85 years (10 to 27%), followed by those among persons aged 65–84 years (3 to 11%), and those among persons aged 55-64 years (1 to 3%) [ 26 ].

On the other hand, regions and countries with low HDI have, to date, experienced less severe epidemics. For instance, as of January 12, 2022, the African region has recorded about 10.3 million cases and 233,000 deaths– far lower than other regions of the world (Table 1 ) [ 27 ]. These might be due to lower testing rates in Africa, where only 6.5% of the population has been tested for the virus [ 14 , 28 ], and a greater proportion of infections may remain asymptomatic [ 29 ]. Indeed, the results from sero-surveys in Africa show that more than 80% of people infected with the virus were asymptomatic compared to an estimated 40-50% asymptomatic infections in HICs [ 30 , 31 ]. Moreover, there is a weak vital registration system in the region indicating that reports might be underestimating and underreporting the disease burden [ 32 ]. However, does this fully explain the differences observed between Africa and Europe or the Americas?

Other possible factors that may explain the lower rates of cases and deaths in Africa include: (1) Africa is less internationally connected than other regions; (2) the imposition of early strict lockdowns in many African countries, at a time when case numbers were relatively small, limited the number of imported cases further [ 2 , 33 , 34 ]; (3) relatively poor road network has also limited the transmission of the virus to and in rural areas [ 35 ]; (4) a significant proportion of the population resides in rural areas while those in urban areas spend a lot of their time mostly outdoors; (5) only about 3% of Africans are over the age of 65 (so only a small proportion are at risk of severe COVID-19) [ 36 ]; (6) lower prevalence of NCDs, as disease burden in Africa comes from infectious causes, including coronaviruses, which may also have cross-immunity that may reduce the risk of developing symptomatic cases [ 37 ]; and (7) relative high temperature (a major source of vitamin D which influences COVID-19 infection and mortality) in the region may limit the spread of the virus [ 38 , 39 ]. We argue that a combination of all these factors might explain the lower COVID-19 burden in Africa.

The early and timely efforts by African leaders should not be underestimated. The African Union, African CDC, and WHO convened an emergency meeting of all African ministers of health to establish an African taskforce to develop and implement a coordinated continent-wide strategy focusing on: laboratory; surveillance; infection prevention and control; clinical treatment of people with severe COVID-19; risk communication; and supply chain management [ 40 ]. In April 2021, African Union and Africa CDC launched the Partnerships for African Vaccine Manufacturing (PAVM), framework to expanding Africa’s vaccine manufacturing capacity for health security [ 41 ].

Heterogeneity of the pandemic among countries with high HDI: what can explain it?

Figures 2 and 3 illustrate the variability of cases and deaths due to the COVID-19 pandemic across high-income countries (HICs). Contrary to the overall positive correlation between high HDI and cases, deaths and fatality rates due to COVID-19, there are outlier HICs, which have been able to control the epidemic. Several HICs, such as New Zealand, Australia, South Korea, Japan, Denmark, Iceland, and Norway, managed to contain their epidemics (Figs. 2 and 3 ) [ 15 , 42 , 43 ]. It is important to note that most of these countries (especially the island states) have far less cross-border mobility than other HICs.

Scatter plot of COVID-19 cases per million population in countries with high human development index (> 0.70)

Scatter plot of COVID-19 deaths per million population in countries with high human development index (> 0.70)

HICs that have been successful at controlling their epidemics have similar characteristics, which are related to governance of the response [ 44 ], synergy between UHC and GHS, and existing relative socio-economic equity in the country. Governance and leadership is a crucial factor to explain the heterogeneity of the epidemic among countries with high HDI [ 45 ]. There has been substantial variation in the nature and timing of the public health responses implemented [ 46 ]. Adaptable and agile governments seem better able to respond to their epidemics [ 47 , 48 ]. Countries that have fared the best are the ones with good governance and public support [ 49 ]. Countries with an absence of coherent leadership and social trust have worse outcomes than countries with collective action, whether in a democracy or autocracy, and rapid mobilisation of resources [ 50 ]. The erosion of trust in the United States government has hurt the country’s ability to respond to the COVID-19 crisis [ 51 , 52 ]. The editors of the New England Journal of Medicine argued that the COVID-19 crisis has produced a test of leadership; but, the leaders in the United States had failed that test [ 47 ].

COVID-19 has exposed the fragility of health systems, not only in the public health and primary care, but also in acute and long-term care systems [ 49 ]. Fragmentation of health systems, defined here to mean inadequate synergy and/ or integration between GHS and UHC, is typical of countries most affected by the COVID-19 pandemic. Even though GHS and UHC agendas are convergent and interdependent, they tend to have different policies and practices [ 53 ]. The United States has the highest index for GHS preparedness; however, it has reported the world’s highest number of COVID-19 cases and deaths due to its greatly fragmented health system [ 54 , 55 ]. Countries with health systems and policies that are able to integrate International Health Regulations (IHR) core capacities with primary health care (PHC) services have been effective at mitigating the effects of COVID-19 [ 50 , 53 ]. Australia has been able to control its COVID-19 epidemic through a comprehensive primary care response, including protection of vulnerable people, provision of treatment and support services to affected people, continuity of regular healthcare services, protection and support of PHC workers and primary care services, and provision of mental health services to the community and the primary healthcare workforce [ 56 ]. Strict implementation of public health and social intervention together with UHC systems have ensured swift control of the epidemics in Singapore, South Korea, and Thailand [ 57 ].

The heterogeneity of cases and deaths, due to COVID-19, is also explained by differences in levels of socio-economic inequalities, which increase susceptibility to acquiring the infection and disease progression as well as worsening of health outcomes [ 58 ]. COVID-19 has been a stress test for public services and social protection systems. There is a higher burden of COVID-19 in Black, Asian and Minority Ethnic individuals due to socio-economic inequities in HICs [ 59 , 60 ]. Poor people are more likely to live in overcrowded accommodation, are more likely to have unstable work conditions and incomes, have comorbidities associated with poverty and precarious living conditions, and reduced access to health care [ 59 ].

The epidemiology of COVID-19 is also variable across MICs, with HDI between 0.70 and 0.85, around the world. Overall, the epidemic in MICs is exacerbated by the rapid demographic and epidemiologic transitions as well as high prevalence of obesity. While India and Brazil witnessed rapidly increasing rates of cases and deaths, China, Thailand, Vietnam have experienced a relatively lower disease burden [ 15 ]. This heterogeneity may be attributed to a number of factors, including governance, communication and service delivery. Thailand, China and Vietnam have implemented a national harmonized strategic response with decentralized implementation through provincial and district authorities [ 61 ]. Thailand increased its testing capacity from two to over 200 certified facilities that could process between 10,000 to 100,000 tests per day; moreover, over a million village health volunteers in Thailand supported primary health services [ 62 , 63 ]. China’s swift and decisive actions enabled the country to contain its epidemic though there was an initial delay in detecting the disease. China has been able to contain its epidemic through community-based measures, very high public cooperation and social mobilization, strategic lockdown and isolation, multi-sector action [ 64 ]. Overall, multi-level governance (effective and decisive leadership and accountability) of the response, together with coordination of public health and socio-economic services, and high levels of citizen adherence to personal protection, have enabled these countries to successfully contain their epidemics [ 61 , 65 , 66 ].

On the other hand, the Brazilian leadership was denounced for its failure to establish a national surveillance network early in the pandemic. In March 2020, the health minister was reported to have stated that mass testing was a waste of public funding, and to have advised against it [ 67 ]. This was considered as a sign of a collapse of public health leadership, characterized by ignorance, neoliberal authoritarianism [ 68 ]. There were also gaps in the public health capacity in different municipalities, which varied greatly, with a considerable number of Brazilian regions receiving less funding from the federal government due to political tension [ 69 ]. The epidemic has a disproportionate adverse burden on states and municipalities with high socio-economic vulnerability, exacerbated by the deep social and economic inequalities in Brazil [ 70 ].

India is another middle-income country with a high burden of COVID-19. It was one of the countries to institute strict measures in the early phase of the pandemic [ 71 , 72 ]. However, the government eased restrictions after the claim that India had beaten the pandemic, which lead to a rapid increase in disease incidence. Indeed, on 12 January 2022, India reported 36 million cumulative cases and almost 485,000 total deaths [ 15 ]. The second wave of the epidemic in India exposed weaknesses in governance and inadequacies in the country’s health and other social systems [ 73 ]. The nature of the Indian federation, which is highly centripetal, has prevented state and local governments from tailoring a policy response to suit local needs. A centralized one-size-fits-all strategy has been imposed despite high variations in resources, health systems capacity, and COVID-19 epidemics across states [ 74 ]. There were also loose social distancing and mask wearing, mass political rallies and religious events [ 75 ]. Rapid community transmission driven by high population density and multigenerational households has been a feature of the current wave in India [ 76 ]. In addition, several new variants of the virus, including the UK (B.1.1.7), the South Africa (20H/501Y or B.1.351), and Brazil (P.1), alongside a newly identified Indian variant (B.1.617), are circulating in India and have been implicated as factors in the second wave of the pandemic [ 75 , 76 ].

Heterogeneity of case-fatality rates around the world: what can explain it?

The pandemic is characterized by variable CFRs across regions and countries that are negatively associated with HDI (Fig.  1 ). The results presented in Fig.  4 show that the proportion of elderly population and rate of obesity are important factors which are positively associated with CFR. On the other hand, UHC, IHR capacity and other indicators of health systems capacity (health workforce density and hospital beds) are negatively associated with the CFR (Figs. 1 and 4 ).

Correlates of COVID-19 cases, deaths and case-fatality rates in 189 countries

The evidence from several research indicates that heterogeneity can be explained by several factors, including differences in age-pyramid, socio-economic status, access to health services, or rates of undiagnosed infections. Differences in age-pyramid may explain some of the observed variation in epidemic severity and CFR between countries [ 77 ]. CFRs across countries look similar when taking age into account [ 78 ]. The elderly and other vulnerable populations in Africa and Asia are at a similar risk as populations in Europe and Americas [ 79 ]. Data from European countries suggest that as high as 57% of all deaths have happened in care homes and many deaths in the US have also occurred in nursing homes. On the other hand, in countries such as Mexico and India, individuals < 65 years contributed the majority of deaths [ 80 ].

Nevertheless, CFR also depends on the quality of hospital care, which can be used to judge the health system capacity, including the availability of healthcare workers, resources, and facilities, which affects outcomes [ 81 ]. The CFR can increase if there is a surge of infected patients, which adds to the strain on the health system [ 82 ]. COVID-19 fatality rates are affected by numerous health systems factors, including bed capacity, existence and capacity of intensive care unit (ICU), and critical care resources (such as oxygen and dexamethasone) in a hospital. Regions and countries with high HDI have a greater number of acute care facilities, ICU, and hospital bed capacities compared to lower HDI regions and countries [ 83 ]. Differences in health systems capacity could explain why North America and Europe, which have experienced much greater number of cases and deaths per million population, reported lower CFRs than the Southern American and the African regions, partly also due to limited testing capacity in these regions (Table 1 ) [ 84 , 85 , 86 ]. The higher CFR in Southern America can be explained by the relatively lower health systems surge capacity that could not adequately respond to the huge demand for health services [ 69 , 86 ]. The COVID-19 pandemic has highlighted existing health systems’ weaknesses, which are not able to effectively prepare for and respond to PHEs [ 87 ]. The high CFRs in the region are also exacerbated by the high social inequalities [ 69 ].

On the other hand, countries in Asia recorded lower CFRs (~ 1.4%) despite sharing many common risk factors (including overcrowding and poverty, weak health system capacity etc) with Africa. The Asian region shares many similar protective factors to the African region. They have been able to minimize their CFR by suppressing the transmission of the virus and flattening the epidemic curve of COVID-19 cases and deaths. Nevertheless, the epidemic in India is likely to be different because it has exceeded the health system capacity to respond and provide basic medical care and medical supplies such as oxygen [ 88 ]. Overall, many Asian countries were able to withstand the transmission of the virus and its effect due to swift action by governments in the early days of the pandemic despite the frequency of travel between China and neighbouring countries such as Hong Kong, Taiwan and Singapore [ 89 ]. This has helped them to contain the pandemic to ensure case numbers remain within their health systems capacity. These countries have benefited from their experience in the past in the prevention and control of epidemics [ 90 ].

There are a number of issues with the use of the CFR to compare the management of the pandemic between countries and regions [ 91 ], as it does not depict the true picture of the mortality burden of the pandemic. A major challenge with accurate calculation of the CFR is the denominator on number of identified cases, as asymptomatic infections and patients with mild symptoms are frequently left untested, and therefore omitted from CFR calculations. Testing might not be widely available, and proactive contact tracing and containment might not be employed, resulting in a smaller denominator, and skewing to a higher CFR [ 82 ]. It is, therefore, far more relevant to estimate infection fatality rate (IFR), the proportion of all infected individuals who have died due to the infection [ 91 ], which is central to understanding the public health impact of the pandemic and the required policies for its prevention and control [ 92 ].

Estimates of prevalence based on sero-surveys, which includes asymptomatic and mildly symptomatic infections, can be used to estimate IFR [ 93 ]. In a systematic review of 17 studies, seroprevalence rates ranged from 0.22% in Brazil to 53% in Argentina [ 94 ]. The review also identified that the seroprevalence estimate was higher than the cumulative reported case incidence, by a factor between 1.5 times in Germany to 717 times in Iran, in all but two studies (0.56 times in Brazil and 0.88 times in Denmark) [ 94 , 95 ]. The difference between seroprevalence and cumulative reported cases might be due to asymptomatic cases, atypical or pauci-symptomatic cases, or the lack of access to and uptake of testing [ 94 ]. There is only a modest gap between the estimated number of infections from seroprevalence surveys and the cumulative reported cases in regions with relatively thorough symptom-based testing. Much of the gap between reported cases and seroprevalence is likely to be due to undiagnosed symptomatic or asymptomatic infections [ 94 ].

Collateral effects of the COVID-19 pandemic

It is important to note that the pandemic has significant collateral effects on the provision of essential health services, in addition to the direct health effects [ 96 ]. Disruptions in the provision of essential health services, due to COVID-19, were reported by nearly all countries, though it is more so in lower-income than higher-income countries [ 97 , 98 ]. The biggest impact reported is on provision of day-to-day primary care to prevent and manage some of the most common health problems [ 99 ].

The causes of disruptions in service delivery were a mix of demand and supply factors [ 100 ]. Countries reported that just over one-third of services were disrupted due to health workforce-related reasons (the most common causes of service disruptions), supply chains, community mistrust and fears of becoming infected, and financial challenge s[ 101 ]. Cognizant of the disruptive effects of the pandemic, countries have reorganized their health system.

Countries with better response to COVID-19 have mobilized, trained and reallocated their health workforce in addition to hiring new staff, using volunteers and medical trainees and mobilizing retirees [ 102 ]. Several strategies have also been implemented to mitigate disruptions in service delivery and utilization, including: triaging to identify the most urgent patient needs, and postponing elective medical procedures; switching to alternative models of care, such as providing more home-based care and telemedicine [ 101 ].

This study identifies that the COVID-19 pandemic, in terms f cases and deaths, is heterogeneous around the world. This variability is explained by differences in vulnerability, preparedness, and response. It confirms that a high level of HDI, UHCI and GHSI are essential but not sufficient to control epidemics [ 103 ]. An effective response to public health emergencies requires a joint and reinforcing implementation of UHC, health emergency and disease control priorities [ 104 , 105 ], as well as good governance and social protection systems [ 106 ]. Important lessons have been learned to cope better with the COVID-19 pandemic and future emerging or re-emerging pandemics. Countries should strengthen health systems, minimize fragmentation of public health, primary care and secondary care, and improve coordination with other sectors. The pandemic has exposed the health effects of longstanding social inequities, which should be addressed through policies and actions to tackle vulnerability in living and working conditions [ 106 ].

The shift in the pandemic epicentre from high-income to MICs was observed in the second global wave of the pandemic. This is due to in part to the large-scale provision of vaccines in HICs [ 15 ] as well as the limitations in the response in LMICs, including inadequate testing, quarantine and isolation, contact tracing, and social distancing. The second wave of the pandemic in low- and middle-income countries spread more rapidly than the first wave and affected younger and healthier populations due to factors, including poor government decision making, citizen behaviour, and the emergence of highly transmissible SARS-CoV-2 variants [ 107 ]. It has become catastrophic in some MICs to prematurely relax key public health measures, such as mask wearing, physical distancing, and hand hygiene [ 108 ].

There is consensus that global vaccination is essential to ending the pandemic. Universal and equitable vaccine delivery, implemented with high volume, speed and quality, is vital for an effective and sustainable response to the current pandemic and future public health emergencies. There is, however, ongoing concern regarding access to COVID-19 vaccines in low-income countries [ 109 ]. Moreover, there is shortage of essential supplies, including oxygen, which has had a major impact on the prevention and control of the pandemic. It is, therefore, vital to transform (through good governance and financing mechanisms) the ACT-A platform to deliver vaccines, therapeutics, diagnostics, and other essential supplies [ 109 , 110 ]. The global health community has the responsibility to address these inequalities so that we can collectively end the pandemic [ 107 ].

The Omicron variant has a huge role in the current wave around the world despite high vaccine coverage [ 111 ]. Omicron appears to spread rapidly around the world ever since it was identified in November 2021 [ 112 ]. It becomes obvious that vaccination alone is inadequate for controlling the infection. This has changed our understanding of the COVID-19 pandemic endgame. The emergence of new variants of concern and their spread around the world has highlighted the importance of combination prevention, including high vaccination coverage in combination with other public health prevention measures [ 112 ].

Overall, the COVID-19 pandemic and the response to it emphasise valuable lessons towards an effective and sustainable response to public health emergencies. We argue that the PHC approach captures the different preparedness and response strategies required towards ensuring health security and UHC [ 113 ]. The PHC approach enables countries to progressively realize universal access to good-quality health services (including essential public health functions) and equity, empower people and communities, strengthen multi-sectoral policy and action for health, and enhance good governance [ 114 ]. These are essential in the prevention and control of public health emergencies, to suppress transmission, and reduce morbidity and mortality [ 115 ]. Access to high-quality primary care is at the foundation of any strong health system [ 116 ], which will, in turn, have effect on containing the epidemic, and reducing mortality and CFR [ 117 ]. Australia is a good example in this regard because it has implemented a comprehensive PHC approach in combination with border restrictions to ensure health system capacity is not exceeded [ 56 ]. The PHC approach will enable countries to develop and implement a context-specific health strategy, enhance governance, strengthen their (public) health systems, minimize segmentation and fragmentation, and tackle upstream structural issues, including discrimination and socio-economic inequities [ 118 ]. This is the type of public health approach (comprehensive, equity-focused and participatory) that will be effective and sustainable to tackle public health emergencies in the twenty-first century [ 119 , 120 ]. In addition, it is vital to transform the global and regional health systems, with a strong IHR and an empowered WHO at the apex [ 121 ]. We contend that this is the way towards a healthier and safer country, region and world.

The COVID-19 pandemic demonstrates that the world remains vulnerable to public health emergencies with significant health and other socio-economic impacts. The pandemic takes variable shapes and forms across regions and countries around the world. The pandemic has impacted countries with inadequate governance of the epidemic, fragmentation of their health systems and higher socio-economic inequities more than others. We argue that adequate response to public health emergencies requires that countries develop and implement a context-specific national strategy, enhance governance of public health emergency, build the capacity of their health systems, minimize fragmentation, and tackle socio-economic inequities. This is possible through a PHC approach that provides universal access to good-quality health services through empowered communities and multi-sectoral policy and action for health development. The pandemic has affected every corner of the world; it has demonstrated that “no country is safe unless other countries are safe”. This should be a call for a strong global health system based on the values of justice and capabilities for health.

Availability of data and materials

Data are available in a public, open access repository: Johns Hopkins University: https://coronavirus.jhu.edu/data/new-cases , and UNDP: http://hdr.undp.org/en/2019-report ; WHO: https://www.who.int/publications/m/item/weekly-epidemiological-update%2D%2D-22-december-2020

Abbreviations

Coronavirus Disease 2019

Case-fatality rates

Human development index

Universal health coverage index

Global Health Security index

High-income countries

Middle-income countries

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The dissertation journey during the COVID-19 pandemic: Crisis or opportunity?

Despite dissertation's significance in enhancing the quality of scholarly outputs in tourism and hospitality fields, insufficient research investigates the challenges and disruptions students experience amidst a public health crisis. This study aims to fill the research gaps and integrate attribution and self-efficacy theories to understand how the COVID-19 pandemic influences students' decision-making and behaviours during the dissertation writing process. Qualitative exploration with 15 graduate students was conducted. The results indicate that adjustment of data collection approaches was the most shared external challenge, while students' religious background and desire for publishing COVID related topics were primary internal motivations.

1. Introduction

Dissertation writing is an essential part of academic life for graduate students ( Yusuf, 2018 ). By writing the dissertation, students can build research skills to analyse new data and generate innovative concepts to inform future scientific studies ( Fadhly et al., 2018 ; Keshavarz & Shekari, 2020 ). Therefore, scholars in higher education are dedicated to guiding students to complete impactful dissertations. Duffy et al. (2018) note that thesis advisors can empower students to explore novel ideas and identify new products or services for the tourism and hospitality industry beyond the traditional contribution of extending the existing research literature. Namely, the intriguing ideas proposed in students’ dissertations will eventually enrich and diversify the literature in the tourism and hospitality academia. Furthermore, the process of identifying impactful ideas will prepare students for a successful career either as a researcher or practitioner.

However, dissertation writing can be a challenging experience for both native and non-native writers. Students are sometimes confused about the characteristics of the dissertation or the expectations from the academics and practitioners ( Bitchener et al., 2010 ). A graduate student has to make numerous decisions during the dissertation writing journey. To successfully guide the students through this complicated writing journey, thesis advisors need to understand the factors influencing students' writing motivation and decision-making process. Previous studies have suggested these influential factors can be broadly classified into external sources (e.g., advisor/supervisor's influence, trends in the field, or publishability of the topic) and internal sources (e.g., researcher's background or researcher interest; Fadhly et al., 2018 ; I'Anson & Smith, 2004 ; Keshavarz & Shekari, 2020 ). Despite this classification, the discussions related to the impacts of macro-environments, such as socio-cultural trends, economic conditions, or ecology and physical environments, on students' dissertation writing are extremely lacking. Since the time background and the world situation when writing a dissertation are also critical factors influencing students' writing goals, more research should be done to broaden students' dissertation writing experiences.

The COVID-19 pandemic has immensely impacted global education, students' learning, and research activities. According to Dwivedi et al. (2020) , the COVID-19 pandemic has affected international higher education leading to the closure of schools to control the spread of the virus. Meanwhile, Alvarado et al. (2021) found that the global health crises have seriously disrupted doctoral students' Dissertations in Practice (DiP). Specifically, students must learn new methodologies and adjust the research settings and sampling techniques because of virtual-only approaches. Some have to find new topics and research questions since the original one cannot be investigated during the quarantine period. However, students may turn this current crisis into an opportunity as they build a shared community and support each other's private and academic lives. Apparently, the crisis can result in a stronger bond of friendship, and this may generate more collaborative research projects in the future.

As mentioned earlier, some studies have tried to identify factors influencing students' dissertation writing journey, albeit lack considerations related to the effects of macro-environments. Given the severe impacts of COVID-19 on the macro-environments of global higher education and the tourism industry, this study aims to fill the research gap and explore how a public health crisis may influence graduate students' dissertation writing, especially in the field of tourism and hospitality. Specifically, this study utilizes attribution and self-efficacy theory as the research framework to examine the internal and external factors that influenced graduate students' dissertation journey amidst the COVID-19 pandemic (see Fig. 1 ). The use of attribution and self-efficacy theory is appropriate in the current study because both explain how people make sense of society, influences of others, their decision-making process and behaviours. Although some may argue these theories are outdated, many scholars have used them to explain students' behaviours and experiences during the COVID-19 pandemic. For example, Xu et al. (2021) found that social capital and learning support positively influence students' self-efficacy, employability and well-being amidst the crisis. Meanwhile, Lassoued et al. (2020) used attribution theory to explore the university professors and their students' learning experience during the COVID-19 pandemic. They found that both groups attributed the problems to reaching high quality in distance learning to students' weak motivation to understand abstract concepts in the absence of in-person interaction.

The theoretical framework.

Understanding the lived experience of students would enable stakeholders in tourism and hospitality education to deeply comprehend the plight and predicaments of students face and the innovate ways to mitigate those challenges amidst the COVID-19 pandemic. Thus, this study utilizes a qualitative approach to explore the impacts of internal and extremal factors on the dissertation writing process. The study was set in the context of an international graduate hospitality and tourism program in Taiwan known for its diverse student body. The research question that guides such qualitative exploration is: How have external and internal factors influenced graduate students’ dissertation writing journey during the COVID-19 pandemic?

This study is timely and critical considering the uncertainties that characterize pandemics which aggravates the already perplexities that associate dissertation writing. It throws light on factors that are susceptible to pandemic tendencies and factors that are resilient to crisis. The findings of this study would provide insights into how crises affect academia and suggest effective ways for higher educational institutions, academicians, and other key stakeholders to forge proactive solutions for future occurrences. Especially, higher education institutions would be well-positioned and informed on areas to train students and faculty members to ameliorate the impacts associated with pandemics.

2. Literature review

2.1. covid-19 and its impacts on educational activities.

Public health crises have ramifications for educational behaviour and choices; this is especially true of the COVID-19 pandemic. Most countries and institutions of higher education are still battling with the consequences suffered from the COVID-19 pandemic. Not surprisingly, there has been a tsunami of studies on the implications of the COVID-19 pandemic (e.g., Dwivedi et al., 2020 ; Manzano-Leon et al., 2021 ; Alam & Parvin, 2021 ). Assessing these studies, we found that although there are substantial extant studies on the negative implications of the COVID-19 pandemic, limited studies have also emphasised the positive side of the pandemic on education. For example, Dwivedi et al. (2020) concluded that the COVID-19 had revealed the necessity of online teaching in higher educational institutions. For they observed that at Loughborough, though face-to-face teaching is practised, one cannot relegate online teaching as some students will be unable to return to campus due to border closures. Thus, faculty members have to convert existing material to the online format. Furthermore, Manzano-Leon et al. (2021) also pointed out that the COVID-19 has allowed students to interact with their peers beyond traditional education. They pinpointed that playful learning strategies such as escape rooms enable students to interact well. Alam and Parvin (2021) also underscored students who studied during the COVID-19 pandemic performed better academically than those before. This finding suggests that online education is supposedly more active than face-to-face mode.

Apart from these positive implications aforementioned, most studies have emphasised the negative impacts of COVID-19 on education. Dwivedi et al. (2020) reviewed how the global higher education sector has been affected by the COVID-19 pandemic. It caused the closure of schools, national lockdowns and social distancing, and a proliferation of online teaching. COVID-19 forced both teachers and students to work and study remotely from home. According to Dhawan (2020) , the rapid deployment of online learning to protect students, faculty, communities, societies, and nations affected academic life. Online learning seemed like a panacea in the face of COVID-19's severe symptoms; however, the switch to online also brought several challenges for teachers and students. Lall and Singh (2020) noted that disadvantages of online learning include the absence of co-curricular activities and students' lack of association with friends at school. Many studies have also confirmed the pandemic's adverse effects on students' mental health, emotional wellbeing, and academic performance ( Bao, 2020 ; de Oliveira Araújo et al., 2020 ).

Despite the pandemic has caused numerous difficulties for many educational institutions, scholars and educators have risen to the challenges and tried to plan effective strategies to mitigate such stressing circumstances. For example, to respond the needs of a better understanding of students' social-emotional competencies for coping the COVID-19 outbreak, Hadar et al. (2020) utilized the VUCA (volatile, uncertain, complex, ambiguous) framework to analyse teachers and students' struggles. Each element of VUCA is defined as follows:

• ● Volatility: the speed and magnitude of the crisis;
• ● Uncertainty: the unpredictability of events during the crisis;
• ● Complexity: the confounding events during the crisis;
• ● Ambiguity: the confusing and mixed meanings during the crisis.

This analysis and conceptualization of crises help to explain some of the students’ concerns on mental health, emotional wellbeing, and academic performance ( Bao, 2020 ; de Oliveira Araújo et al., 2020 ).

The pandemic also exacerbated existing challenges facing students and universities across the globe. According to Rose-Redwood et al. (2020) , the COVID-19 endangered the career prospects of both students and scholars. University partnerships with the arts sector, community service, and non-governmental organizations also suffered. The tourism and hospitality (academic) field faced unique challenges in light of COVID-19 without exception. Forms of tourism such as over-tourism and cruise tourism were temporarily unobservable, and most pre-crisis studies and forecast data were no longer relevant ( Bausch et al., 2021 ). Consequently, many empirical and longitudinal studies were halted due to the incomparability of data. Even though many studies have been conducted to explore the impacts of the COVID pandemic on educational activities, none of these studies has addressed how this public health crisis has affected graduate students’ dissertation journey. Therefore, the present research is needed to fill the gaps in the mainstream literature.

2.2. Attribution theory and self-efficacy

The current study employs attribution theory and self-efficacy to understand graduate students' dissertation writing journeys. Attribution theory explains how individuals interpret behavioural outcomes ( Weiner, 2006 ) and has been used in education and crisis management ( Abraham et al., 2020 ; Sanders et al., 2020 ). For example, Chen and Wu (2021) used attribution theory to understand the effects of attributing students' academic achievements to giftedness. They found that attributing students' academic success to giftedness had a positive indirect relationship with their academic achievement through self-regulated learning and negative learning emotions. However, attribution theory has been criticised for its inability to explain a person's behaviour comprehensively. This is well enunciated by Bandura (1986) that attribution theory does not necessarily describe all influential factors related to a person's behaviour. Instead, it provides in-depth accounts of one's self-efficacy. Hence, scholars have advocated the need for integrating self-efficacy into attribution theory ( Hattie et al., 2020 ).

Self-efficacy is closely related to attribution theory. Extant studies have investigated the essence of self-efficacy in education and its role on students' achievements ( Bartimote-Aufflick et al., 2016 ; Hendricks, 2016 ). For instance, in their educational research and implications for music, Hendricks (2016) found that teachers can empower students' ability and achievement through positive self-efficacy beliefs. This is achieved through Bandura's (1986) theoretical four sources of self-efficacy: vicarious experience, verbal/social persuasion, enactive mastery experience, and physiological and affective states. The current study integrates attribution theory and self-efficacy as the research framework to provide intellectual rigour and reasons underlined students' decision-making during their dissertation journey.

2.3. Internal and external factors that influence dissertation writing processes

This study considered both internal and external factors affecting graduate students' dissertation journeys in line with attribution theory. Internal factors are actions or behaviours within an individual's control ( LaBelle & Martin, 2014 ; Weiner, 2006 ). Many studies have evolved and attributed dissertation topic selection to internal considerations. For instance, I'Anson and Smith's (2004) study found that personal interest and student ability were essential for undergraduate students' thesis topic selection. Keshavarz and Shekari (2020) also found that personal interest is the primary motivation for choosing a specific thesis topic. In another study focused on undergraduate students at the English department, Husin and Nurbayani (2017) revealed that students' language proficiency was a dominant internal factor for their dissertation choice decisions.

On the other hand, external factors are forces beyond an individual's control ( LaBelle & Martin, 2014 ). Similar to internal factors, there is an avalanche of studies that have evolved and uncovered external factors that characterize students' dissertation decisions in the pre-COVID period (e.g., de Kleijn et al., 2012 ; Huin; Nurbayani, 2017 ; Keshavarz & Shekari, 2020 ; Pemberton, 2012 ; Shu et al., 2016; Sverdlik et al., 2018 ). For instance, de Kleijn et al. (2012) found that supervisor influence is critical in the student dissertation writing process. They further revealed that an acceptable relationship between supervisor and student leads to a higher and quality outcome; however, a high level of influence could lead to low satisfaction. Meanwhile, Pemberton (2012) delved into the extent teachers influence students in their dissertation process and especially topic selection. This study further underlined that most supervisors assist students to select topics that will sustain their interest and competence level. Unlike previous research, Keshavarz and Shekari (2020) found that research operability or feasibility was a critical external factor that informed students' dissertation decisions. In other words, practicality and usefulness are essential in determining the dissertation choices.

These studies above show how internal and external factors may determine students' dissertation decisions. Despite those studies providing valuable knowledge to broaden our understanding of which factors may play significant role in students' dissertation journeys, most of their focus was on undergraduate students and was conducted before COVID-19. Given that the learning experiences among graduate and undergraduate students as well as before and during the pandemic may differ significantly, there is a need to investigate what specific external and internal factors underline graduate students’ dissertation decisions during the COVID-19. Are those factors different from or similar to previous findings?

3. Methodology

Previous studies have disproportionately employed quantitative approaches to examine students' dissertation topic choice (e.g., Keshavarz & Shekari, 2020 ). Although the quantitative method can aid the researcher to investigate focal phenomena among larger samples and generalize the results, it has also been criticized for the lack of in-depth analysis or does not allow respondents to share their lived experiences. Given the rapid evolution and uncertainty linked with the COVID-19 pandemic, the contextual and social factors may drive individuals to respond to such challenges differently. Therefore, efforts toward analyzing individual experiences during the public health crisis are necessary to tailor individual needs and local educational policy implementation ( Tremblay et al., 2021 ). Accordingly, the current study adopts a qualitative approach grounded in the interpretivism paradigm to explore the factors affecting graduate students’ dissertation research activities and understand the in-depth meaning of writing a dissertation.

3.1. Data collection

Since statistical representation is not the aim of qualitative research, the purposive sampling instead of probability sampling technique was used for this study ( Holloway & Wheeler, 2002 ). Graduate students who were composing their dissertation and could demonstrate a clear understanding on the issues under study are selected as the target research subjects. To gain a rich data, the sample selection in the current study considers background, dissertation writing status, and nationality to ensure a diversified data set ( Ritchie et al., 2014 ). Data was collected from graduate students in Taiwan who were currently writing their dissertations. Taiwan was chosen as the research site because the pandemic initially had a minor impact on Taiwan than on other economically developed countries ( Wang et al., 2020 ). In the first year (2019–2020) of their study, the graduate students could conduct their research projects without any restrictions. Therefore, traditional data collections and research processes, such as face-to-face interview techniques or onsite questionnaire distributions were generally taught and implemented in Taiwanese universities at that time. However, in their second year of the graduate program (2021), the COVID-19 cases surged, and the government identified some domestic infection clusters in Taiwan. Thus, the ministry of education ordered universities to suspend in-person instruction and move to online classes from home as part of a national level 3 COVID-19 alert. Many graduate students have to modify their data collection plan and learn different software to overcome the challenges of new and stricter rules. As they have experienced the sudden and unexpected change caused by the COVID-19 in their dissertation writing journey, Taiwanese graduate students are deemed as suitable research participants in this research.

Following Keshavarz and Shekari (2020) , interview questions were extracted from the literature review and developed into a semi-structured guide. Semi-structured interview was employed allowing for probing and clarifying explanations. This also allowed both the interviewer and the interviewee to become co-researchers (Ritchie et al., 2005). The questions asked about internal, and external factors influencing dissertation writing (including topic selection and methodology) during COVID-19. Specifically, students were asked how they chose their dissertation topic, how they felt COVID-19 had impacted their dissertation, and what significant events influenced their academic choices during the pandemic. Before each interview, the purpose of the study was explained and respondents provided informed consent. All the interviews were audio-recorded and later transcribed.

Interviews, lasting about 50–60 min, were conducted with 15 graduate students as data saturation was achieved after analysing 15 interviews. The saturation was confirmed by the repetition of statements like, “personal interest motivated me”, “my supervisor guided me to select a topic”, and “I changed my data collection procedure to online”.

3.2. Data analysis and trustworthiness

Before the formal interview, two educational experts who are familiar with qualitative research were solicited to validate the wording, semantics, and meanings of the interview questions. Then, a pilot test was conducted with three graduate students to check the clarity of the expression for every interview question and revise potentially confusing phrasing. Validity and trustworthiness were also achieved through the use of asking follow-up questions. The transcripts of formal interviews were analysed using Atlas.ti 9. Qualitative themes were developed following open, selective, and axial coding procedures ( Corbin & Strauss, 1990 ). Finally, the relationships among themes and codes were identified, facilitating the research findings and discussions.

In order to prevent biases from affecting the findings of the study, series of procedures were undertaken following previous qualitative research. First, multiple quotations from respondents underlined the research findings which meant the respondents' true perspectives and expressions were represented. Moreover, the analyses were done independently and there was peer checking among the authors. There was also member checking where themes found were redirected to respondents for verification. In addition, external validation of the themes was done by asking other graduate students who share similar characteristics for comparability assessment to make the findings transferable.

4. Results and discussion

4.1. profile of respondents.

Respondents were purposively drawn from diverse backgrounds (including nationality, gender, and programs) to enrich the research findings. The sample includes graduate students who began dissertation writing in Taiwan during the COVID-19 pandemic period. The majority of the respondents are female and from South East Asia. Table 1 provides background information of these interviewees.

Background information of study respondents.

4.2. Internal factors

As Table 2 depicts, the themes ascertained from the data analysis were categorised according to internal and external factors which underpin the attribution theory ( Weiner, 2006 ). In consonance with previous studies, graduate students’ dissertation writing during the pandemic was influenced by internal factors (i.e., personal interest and religious background) and external considerations (i.e., career aspirations, society improvement, language issues, supervisor influence, COVID-19 publishable topics, data collection challenges). The analyses of each factor are presented below.

Major themes and codes emerging from the data.

The most salient internal factors affecting dissertation topic selection were (1) personal interest and (2) religious background. For personal interest, respondent 1 expressed:

The first thing is that [it] comes from my interest. I'm currently working on solo female traveller [s], which is the market I want to study. So, the priority comes from my personal preference and to learn about this market no matter the external situation. I also think that this is due to how I was brought up. My parent nurtured me that way, and I love to do things independently, especially when travelling.

This finding is in line with previous studies such as Keshavarz and Shekari (2020) ; I’Anson and Smith (2004) , who emphasised the relevance of personal interest in students' dissertation decision-making. Informed by the self-efficacy and attribution theories, we found that students who attribute their decision-making on dissertation writing to internal factors (i.e., personal interest) have relatively high self-efficacy levels. As argued by Bandura (1977) , efficacy expectation is “the conviction that one can successfully execute the behaviour required to produce the outcomes” (p. 193). Namely, self-efficacy is determined by an individual's capability and ability to execute decisions independently, devoid of any external considerations. Despite the uncertainties and challenging circumstances amidst COVID-19, students who believe their ability and research skills usually adhere to their original dissertation topics and directions.

Religious consideration is another conspicuous factor informing graduate students' dissertation journey during the COVID-19 pandemic. As respondent 7 mentioned:

Islam has become my way of life. I am a Muslim. It is my daily life, so I like to research this. I was born into this faith, and I am inclined to explore Halal food. I feel committed to contributing my research to my faith no matter outside circumstances. Maybe if I combine it with academic (research), it will be easier to understand and easier to do.

Although not much has been seen regarding religious considerations in students' dissertation topic selection in previous studies, this research reveals religious background as a significant internal factor. From a sociology perspective, religious orientation and affiliation could affect individual behaviour ( Costen et al., 2013 ; Lee & Robbins, 1998 ), and academic decision-making is not an exception. Religious backgrounds are inherent in the socialisation process and could affect how a person behaves or how they make a particular decision. This premise is further accentuated by Costen et al. (2013) , who argued that social connectedness affects college students' ability to adjust to new environments and situations. Social connectedness guides feelings, thoughts, and behaviour in many human endeavours ( Lee & Robbins, 1998 ). Social connectedness and upbringing underpin peoples' personality traits and behavioural patterns. Therefore, this study has extended existing literature on factors that affect graduate students' decision-making on dissertation writing from a religious perspective, which is traceable to an individual's socialisation process. In other words, during crises, most students are inclined to make decisions on their dissertation writing which are informed by their social upbringing (socialisation).

4.3. External factors

As Table 2 indicates, abundant external factors inform graduate students’ decision-making on their dissertation writing process. Except for career aspirations, language concerns, and supervisor influences that previous studies have recognized ( Chu, 2015 ; Jensen, 2013 ; Keshavarz & Shekari, 2020 ; Lee & Deale, 2016 ; Tuomaala et al., 2014 ), some novel factors were identified from the data, such as “COVID-19 publishable topic” and “online data collection restrictions”.

Unlike extant studies that have bemoaned the negative impacts of the COVID on education ( Qiu et al., 2020 ; Sato et al., 2021 ), the current study revealed that graduate students were eager to research on topics that were related to COVID-19 to reflect the changes of the tourism industry and trends.

Initially, overtourism [was] a problem in my country, and I want to write a dissertation about it. However, there is no tourism at my research site because of the COVID-19 pandemic. So, I had to change my topic to resilience because resilience is about overcoming a crisis. I had to discuss with my supervisor, and she suggested the way forward that I revise my topic to make it relevant and publishable due to the COVID-19 pandemic (respondent 8).

This response shows the unavoidable impacts of the COVID-19 on the research community. As Bausch et al. (2021) pointed out, tourism and hospitality scholars have to change their research directions because some forms of tourism such as overtourism and cruise tourism were temporarily unobservable amidst the pandemic. Thus, many pre-pandemic studies and forecast data were no longer relevant. However, the COVID-19 pandemic can bring some positive changes. Nowadays, the industry and academics shift their focus from pro-tourism to responsible tourism and conduct more research related to resilience. As Ting et al. (2021) suggested, “moving forward from the pandemic crisis, one of the leading roles of tourism scholars henceforth is to facilitate high-quality education and training to prepare future leaders and responsible tourism practitioners to contribute to responsible travel and tourism experiences.” (p. 6).

Furthermore, the COVID-19 pandemic has significant ramifications upon the research methods in hospitality and tourism. As respondent 1 denoted,

Because of [the] COVID-19 pandemic, there were certain limitations like I cannot analyse interviewee's body language due to social distancing … some interruptions when we conduct online interviews due to unstable internet connectivity, which would ultimately affect the flow of the conversation.

The adjustments of research methods also bring frustrations and anxiety to students. For instance, respondent 3 expressed: “I became anxious that I won't be able to collect data because of social distancing, which was implemented in Taiwan.” The volatile, uncertain, complex, and ambiguous (VUCA) feelings caused by the COVID-19 pandemic significantly influences students' mood, thinking and behaviour ( Hadar et al., 2020 ).

Apparently, during crises, graduate students' decision-making on their dissertation writing was precipitated by external considerations beyond their control. Based on self-efficacy and attribution theory, the fear that characterises crises affects students' self-efficacy level and eagerness to resort to external entities (e.g., supervisor influences or difficulties in collecting data) to assuage their predicament. In other words, some students may have a low self-efficacy level during the COVID-19 pandemic, which was triggered by the negative impacts of the crisis. Furthermore, scholars may need to notice that COVID-19 is likely to affect conclusions drawn on studies undertaken during this period due to over-reliance on online data collection.

5. Conclusions and implications

Although numerous studies have been conducted to understand the influences of the COVID-19 crisis on educational activities, none of them focuses on the graduate student's dissertation writing journey. Given the significant contributions dissertations may make to advancing tourism and hospitality knowledge, this study aims to fill the gap and uses attribution and self-efficacy theories to explore how internal and external factors influenced graduate students' decision-making for dissertations amidst the crisis. Drawing on qualitative approaches with graduate students who began writing their dissertation during the COVID-19 period, the study provides insights into students' learning experiences and informs stakeholders in hospitality and tourism education to make better policies.

There are several findings worthy of discussion. Firstly, graduate students' sociological background (i.e., personal interest and religious background), which is inherent in an individual's socialisation processes, inform their decision-making in the dissertation processes during the COVID-19 pandemic. This is in line with the self-efficacy theory, which argues that an individual has the conviction that they have the necessary innate abilities to execute an outcome ( Bandura, 1977 ). Namely, respondents with high self-efficacy levels attributed their decisions to internal factors. Unlike previous studies' findings that personal interest was a factor that underpinned graduate students' decision-making ( I'Anson & Smith, 2004 ; Keshavarz & Shekari, 2020 ), it is observed that religious background is an additional factor that was evident and conspicuous during the COVID-19 pandemic.

Secondly, the complexity and uncertainty that characterised the COVID-19 pandemic made emotion a dominant factor that affected graduate students’ dissertation journey and indirectly triggered other external factors that provoked behavioural adjustments among students. The trepidation and anxiety that COVID-19 has caused significantly affects the self-efficacy level of students and predisposes them to external considerations, such as the will of the supervisor or the difficulties in data collection, in their dissertation journey. This study paralleled previous research and revealed that respondents with low self-efficacy were influenced by external considerations more than individuals with high self-efficacy ( Bandura, 1977 ). However, this study highlights how a public health crisis accelerates students who have low self-efficacy to attribute their unsatisfactory academic life to the external environment, leading to depression and negative impacts on ideology ( Abood et al., 2020 ).

Lastly, the COVID-19 pandemic has dramatically influenced the direction of research and body of knowledge in tourism and hospitality. This is seen in the light of the influx of COVID-19 related research topics adapted by graduate students. Furthermore, over-reliance on online data collection approaches were observed in this research. Although online surveys and interviews have many advantages, such as low cost and no geographic restrictions, the results drawn from this approach frequently suffer from biased data and issues with reliability and validity. For example, Moss (2020) revealed that survey respondents from Amazon MTurk are mostly financially disadvantaged, significantly younger than the U.S. population, and predominantly female. As more and more students collect data from online survey platforms such as Amazon MTurk, dissertation advisors may need to question the representativeness of the study respondents in their students’ dissertation and the conclusions they make based on this population.

5.1. Theoretical implications and future study suggestions

This paper has extended the attribution and self-efficacy theories by revealing that a public health crisis moderates attributive factors that underpinned the decision-making of individuals. The integration of self-efficacy theory and attributive theory has proven to better unravel the behaviour of graduate students during the COVID-19 pandemic than solely utilizing one of them. The application and extension of the self-efficacy and attribution theories are rarely observed in the context of hospitality and tourism education, and thus, this study creates the foundation for future scholars to understand students’ attitudes and behaviour in our field.

The findings highlight some factors triggered by the COVID-19 pandemic and have not been identified previously. For example, the religious background was a significant driver to selecting a particular research topic. This research also shows a shift in research direction to hot and publishable issues related to COVID-19. The utility of the dissertation becomes a significant consideration among graduate students. Additionally, emotion is recognized as another critical factor affecting the dissertation writing journey. The current study informs academia and the research community on the extent to which the COVID-19 would influence idea generation and the direction of research in the foreseeable future, as extant studies have overlooked this vital connection. Future studies should consider those factors when investigating relevant behaviours and experiences.

The time that the current study was done is likely to affect the findings. Therefore, it is recommended that future research explore graduate students’ dissertation journey in the post-COVID-19 era to ascertain whether there will be similarities or differences. This would help to give a comprehensive picture of the impacts of the COVID-19 on education. Moreover, the findings of this study cannot be generalised as it was undertaken at a particular Taiwanese institution. We recommend that quantitative research with larger samples could be conducted to facilitate the generalisation of the findings. Finally, it is suggested that a meta-analysis or systematic literature review on articles written on the COVID-19 pandemic and education could be done to further identify more influential factors related to the public health crisis and educational activities.

5.2. Practical implications for hospitality and tourism education

The findings revealed that negative emotion might trigger students' attribution to external factors that affected the dissertation journey. Thus, relevant stakeholders should develop strategies and innovate ways to ease the fears and anxieties of the COVID-19 pandemic. This study calls for immediate actions to prevent spillover effects on upcoming students. Faculty members, staff, and teachers should be trained on soft skills such as empathy, flexibility, and conflict solutions required by the hospitality and tourism industry.

Moreover, the thesis supervisors should notice students' over-reliance on online data collection due to the COVID-19 pandemic. As it may possibly affect the quality and findings of their students' dissertations, there should be sound and logical justification for this decision. Collecting data online should be backed by the appropriateness of the method and the research problem under study instead of the convenience of obtaining such data. There is an urgent need for students to be guided for innovative data collection methods. The school can turn the COVID-19 crisis into an opportunity to improve the online teaching materials and equipment. The research programs may consider including more teaching hours on online research design or data collection procedures to bring positive discussions on the strengths of such approaches.

Credit author statement

Emmanuel Kwame Opoku: Conceptualization, Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing, Project administration. Li-Hsin Chen: Conceptualization, Supervision, Review, Editing, Response to reviewers. Sam Yuan Permadi: Investigation, Visualization, Project administration.

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Open Access

Peer-reviewed

Research Article

The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study

Contributed equally to this work with: Dominika Maison, Diana Jaworska, Dominika Adamczyk, Daria Affeltowicz

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Affiliation Faculty of Psychology, University of Warsaw, Warsaw, Poland

Roles Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Conceptualization, Formal analysis, Investigation, Methodology

• Dominika Maison, 
• Diana Jaworska, 
• Dominika Adamczyk, 
• Daria Affeltowicz

• Published: October 11, 2021
• https://doi.org/10.1371/journal.pone.0258133
• Peer Review
• Reader Comments

The conducted qualitative research was aimed at capturing the biggest challenges related to the beginning of the COVID-19 pandemic. The interviews were carried out in March-June (five stages of the research) and in October (the 6 th stage of the research). A total of 115 in-depth individual interviews were conducted online with 20 respondents, in 6 stages. The results of the analysis showed that for all respondents the greatest challenges and the source of the greatest suffering were: a) limitation of direct contact with people; b) restrictions on movement and travel; c) necessary changes in active lifestyle; d) boredom and monotony; and e) uncertainty about the future.

Citation: Maison D, Jaworska D, Adamczyk D, Affeltowicz D (2021) The challenges arising from the COVID-19 pandemic and the way people deal with them. A qualitative longitudinal study. PLoS ONE 16(10): e0258133. https://doi.org/10.1371/journal.pone.0258133

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: April 6, 2021; Accepted: September 18, 2021; Published: October 11, 2021

Copyright: © 2021 Maison 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: All relevant data are within the manuscript and its Supporting Information files ( S1 Dataset ).

Funding: This work was supported by the Faculty of Psychology, University of Warsaw, Poland from the funds awarded by the Ministry of Science and Higher Education in the form of a subsidy for the maintenance and development of research potential in 2020 (501-D125-01-1250000). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

Introduction

The coronavirus disease (COVID-19), discovered in December 2019 in China, has reached the level of a pandemic and, till June 2021, it has affected more than 171 million people worldwide and caused more than 3.5 million deaths all over the world [ 1 ]. The COVID-19 pandemic as a major health crisis has caught the attention of many researchers, which has led to the creation of a broad quantitative picture of human behavior during the coronavirus outbreak [ 2 – 4 ]. What has been established so far is, among others, the psychological symptoms that can occur as a result of lockdown [ 2 ], and the most common coping strategies [ 5 ]. However, what we still miss is an in-depth understanding of the changes in the ways of coping with challenges over different stages of the pandemic. In the following study, we used a longitudinal qualitative method to investigate the challenges during the different waves of the coronavirus pandemic as well as the coping mechanisms accompanying them.

In Poland, the first patient was diagnosed with COVID-19 on the 4 th March 2020. Since then, the number of confirmed cases has grown to more than 2.8 million and the number of deaths to more than 73,000 (June 2021) [ 1 ]. From mid-March 2020, the Polish government, similarly to many other countries, began to introduce a number of restrictions to limit the spread of the virus. These restrictions had been changing from week to week, causing diverse reactions in people [ 6 ]. It needs to be noted that the reactions to such a dynamic situation cannot be covered by a single study. Therefore, in our study we used qualitative longitudinal research in order to monitor changes in people’s emotions, attitudes, and behavior. So far, few longitudinal studies have been carried out that investigated the various issues related to the COVID-19 pandemic; however, all of them were quantitative [ 7 – 10 ]. The qualitative approach (and especially the use of enabling and projective techniques) allows for an in-depth exploration of respondents’ reactions that goes beyond respondents’ declarations and captures what they are less aware of or even unconscious of. This study consisted of six stages of interviews that were conducted at key moments for the development of the pandemic situation in Poland. The first stage of the study was carried out at the moment of the most severe lockdown and the biggest restrictions (March 2020) and was focused on exploration how did people react to the new uncertain situation. The second stage of the study was conducted at the time when restrictions were extended and the obligation to cover the mouth and nose everywhere outside the household were introduced (middle of April 2020) and was focused at the way how did people deal with the lack of family gatherings over Easter. The third stage of the study was conducted at the moment of announcing the four stages of lifting the restrictions (April 2020) and was focused on people’s reaction to an emerging vision of getting back to normalcy. The fourth stage of the study was carried out, after the introduction of the second stage of lifting the restrictions: shopping malls, hotels, and cultural institutions were gradually being opened (May 2020). The fifth stage of the study was conducted after all four stages of restriction lifting were in place (June 2020). Only the obligation to cover the mouth and nose in public spaces, an order to maintain social distance, as well as the functioning of public places under a sanitary regime were still in effect. During those 5 stages coping strategies with the changes in restrictions were explored. The sixth and last stage of the study was a return to the respondents after a longer break, at the turn of October and November 2020, when the number of coronavirus cases in Poland began to increase rapidly and the media declared “the second wave of the pandemic”. It was the moment when the restrictions were gradually being reintroduced. A full description of the changes occurring in Poland at the time of the study can be found in S1 Table .

The following study is the first qualitative longitudinal study investigating how people cope with the challenges arising from the COVID-19 pandemic at its different stages. The study, although conducted in Poland, shows the universal psychological relations between the challenges posed by the pandemic (and, even more, the restrictions resulting from the pandemic, which were very similar across different countries, not only European) and the ways of dealing with them.

Literature review

The COVID-19 pandemic has led to a global health crisis with severe economic [ 11 ], social [ 3 ], and psychological consequences [ 4 ]. Despite the fact that there were multiple crises in recent years, such as natural disasters, economic crises, and even epidemics, the coronavirus pandemic is the first in 100 years to severely affect the entire world. The economic effects of the COVID-19 pandemic concern an impending global recession caused by the lockdown of non-essential industries and the disruption of production and supply chains [ 11 ]. Social consequences may be visible in many areas, such as the rise in family violence [ 3 ], the ineffectiveness of remote education, and increased food insecurity among impoverished families due to school closures [ 12 ]. According to some experts, the psychological consequences of COVID-19 are the ones that may persist for the longest and lead to a global mental health crisis [ 13 ]. The coronavirus outbreak is generating increased depressive symptoms, stress, anxiety, insomnia, denial, fear, and anger all over the world [ 2 , 14 ]. The economic, social, and psychological problems that people are currently facing are the consequences of novel challenges that have been posed by the pandemic.

The coronavirus outbreak is a novel, uncharted situation that has shaken the world and completely changed the everyday lives of many individuals. Due to the social distancing policy, many people have switched to remote work—in Poland, almost 75% of white-collar workers were fully or partially working from home from mid-March until the end of May 2020 [ 15 ]. School closures and remote learning imposed a new obligation on parents of supervising education, especially with younger children [ 16 ]. What is more, the government order of self-isolation forced people to spend almost all their time at home and limit or completely abandon human encounters. In addition, the deteriorating economic situation was the cause of financial hardship for many people. All these difficulties and challenges arose in the aura of a new, contagious disease with unexplored, long-lasting health effects and not fully known infectivity and lethality [ 17 ]. Dealing with the situation was not facilitated by the phenomenon of global misinformation, called by some experts as the “infodemic”, which may be defined as an overabundance of information that makes it difficult for people to find trustworthy sources and reliable guidance [ 18 ]. Studies have shown that people have multiple ways of reacting to a crisis: from radical and even violent practices, towards individual solutions and depression [ 19 ]. Not only the challenges arising from the COVID-19 pandemic but also the ways of reacting to it and coping with it are issues of paramount importance that are worth investigating.

The reactions to unusual crisis situations may be dependent on dispositional factors, such as trait anxiety or perceived control [ 20 , 21 ]. A study on reactions to Hurricane Hugo has shown that people with higher trait anxiety are more likely to develop posttraumatic symptoms following a natural disaster [ 20 ]. Moreover, lack of perceived control was shown to be positively related to the level of distress during an earthquake in Turkey [ 21 ]. According to some researchers, the COVID-19 crisis and natural disasters have much in common, as the emotions and behavior they cause are based on the same primal human emotion—fear [ 22 ]. Both pandemics and natural disasters disrupt people’s everyday lives and may have severe economic, social and psychological consequences [ 23 ]. However, despite many similarities to natural disasters, COVID-19 is a unique situation—only in 2020, the current pandemic has taken more lives than the world’s combined natural disasters in any of the past twenty years [ 24 ]. It needs to be noted that natural disasters may pose different challenges than health crises and for this reason, they may provoke disparate reactions [ 25 ]. Research on the reactions to former epidemics has shown that avoidance and safety behaviors, such as avoiding going out, visiting crowded places, and visiting hospitals, are widespread at such times [ 26 ]. When it comes to the ways of dealing with the current COVID-19 pandemic, a substantial part of the quantitative research on this issue focuses on coping mechanisms. Studies have shown that the most prevalent coping strategies are highly problem-focused [ 5 ]. Most people tend to listen to expert advice and behave calmly and appropriately in the face of the coronavirus outbreak [ 5 ]. Problem-focused coping is particularly characteristic of healthcare professionals. A study on Chinese nurses has shown that the closer the problem is to the person and the more fear it evokes, the more problem-focused coping strategy is used to deal with it [ 27 ]. On the other hand, a negative coping style that entails risky or aggressive behaviors, such as drug or alcohol use, is also used to deal with the challenges arising from the COVID-19 pandemic [ 28 ]. The factors that are correlated with negative coping include coronavirus anxiety, impairment, and suicidal ideation [ 28 ]. It is worth emphasizing that social support is a very important component of dealing with crises [ 29 ].

Scientists have attempted to systematize the reactions to difficult and unusual situations. One such concept is the “3 Cs” model created by Reich [ 30 ]. It accounts for the general rules of resilience in situations of stress caused by crises, such as natural disasters. The 3 Cs stand for: control (a belief that personal resources can be accessed to achieve valued goals), coherence (the human desire to make meaning of the world), and connectedness (the need for human contact and support) [ 30 ]. Polizzi and colleagues [ 22 ] reviewed this model from the perspective of the current COVID-19 pandemic. The authors claim that natural disasters and COVID-19 pandemic have much in common and therefore, the principles of resilience in natural disaster situations can also be used in the situation of the current pandemic [ 22 ]. They propose a set of coping behaviors that could be useful in times of the coronavirus outbreak, which include control (e.g., planning activities for each day, getting adequate sleep, limiting exposure to the news, and helping others), coherence (e.g., mindfulness and developing a coherent narrative on the event), and connectedness (e.g., establishing new relationships and caring for existing social bonds) [ 22 ].

Current study

The issue of the challenges arising from the current COVID-19 pandemic and the ways of coping with them is complex and many feelings accompanying these experiences may be unconscious and difficult to verbalize. Therefore, in order to explore and understand it deeply, qualitative methodology was applied. Although there were few qualitative studies on the reaction to the pandemic [e.g., 31 – 33 ], they did not capture the perception of the challenges and their changes that arise as the pandemic develops. Since the situation with the COVID-19 pandemic is very dynamic, the reactions to the various restrictions, orders or bans are evolving. Therefore, it was decided to conduct a qualitative longitudinal study with multiple interviews with the same respondents [ 34 ].

The study investigates the challenges arising from the current pandemic and the way people deal with them. The main aim of the project was to capture people’s reactions to the unusual and unexpected situation of the COVID-19 pandemic. Therefore, the project was largely exploratory in nature. Interviews with the participants at different stages of the epidemic allowed us to see a wide spectrum of problems and ways of dealing with them. The conducted study had three main research questions:

• What are the biggest challenges connected to the COVID-19 pandemic and the resulting restrictions?
• How are people dealing with the pandemic challenges?
• What are the ways of coping with the restrictions resulting from a pandemic change as it continues and develops (perspective of first 6 months)?

The study was approved by the institutional review board of the Faculty of Psychology University of Warsaw, Poland. All participants were provided written and oral information about the study, which included that participation was voluntary, that it was possible to withdraw without any consequences at any time, and the precautions that would be taken to protect data confidentiality. Informed consent was obtained from all participants. To ensure confidentiality, quotes are presented only with gender, age, and family status.

The study was based on qualitative methodology: individual in-depth interviews, s which are the appropriate to approach a new and unknown and multithreaded topic which, at the beginning of 2020, was the COVID-19 pandemic. Due to the need to observe respondents’ reactions to the dynamically changing situation of the COVID-19 pandemic, longitudinal study was used where the moderator met on-line with the same respondent several times, at specific time intervals. A longitudinal study was used to capture the changes in opinions, emotions, and behaviors of the respondents resulting from the changes in the external circumstances (qualitative in-depth interview tracking–[ 34 ]).

The study took place from the end of March to October 2020. Due to the epidemiological situation in the country interviews took place online, using the Google Meets online video platform. The audio was recorded and then transcribed. Before taking part in the project, the respondents were informed about the purpose of the study, its course, and the fact that participation in the project is voluntary, and that they will be able to withdraw from participation at any time. The respondents were not paid for taking part in the project.

Participants.

In total, 115 interviews were conducted with 20 participants (6 interviews with the majority of respondents). Two participants (number 11 and 19, S2 Table ) dropped out of the last two interviews, and one (number 6) dropped out of the last interview. The study was based on a purposive sample and the respondents differed in gender, age, education, family status, and work situation (see S2 Table ). In addition to demographic criteria intended to ensure that the sample was as diverse as possible, an additional criterion was to have a permanent Internet connection and a computer capable of online video interviewing. Study participants were recruited using the snowball method. They were distant acquaintances of acquaintances of individuals involved in the study. None of the moderators knew their interviewees personally.

A total of 10 men and 10 women participated in the study; their age range was: 25–55; the majority had higher education (17 respondents), they were people with different professions and work status, and different family status (singles, couples without children, and families with children). Such diversity of respondents allowed us to obtain information from different life perspectives. A full description of characteristics of study participants can be found in S2 Table .

Each interview took 2 hours on average, which gives around 240 hours of interviews. Subsequent interviews with the same respondents conducted at different intervals resulted from the dynamics of the development of the pandemic and the restrictions introduced in Poland by the government.

The interviews scenario took a semi-structured form. This allowed interviewers freely modify the questions and topics depending on the dynamics of the conversation and adapt the subject matter of the interviews not only to the research purposes but also to the needs of a given respondent. The interview guides were modified from week to week, taking into account the development of the epidemiological situation, while at the same time maintaining certain constant parts that were repeated in each interview. The main parts of the interview topic guide consisted of: (a) experiences from the time of previous interviews: thoughts, feeling, fears, and hopes; (b) everyday life—organization of the day, work, free time, shopping, and eating, etc.; (c) changes—what had changed in the life of the respondent from the time of the last interview; (d) ways of coping with the situation; and (e) media—reception of information appearing in the media. Additionally, in each interview there were specific parts, such as the reactions to the beginning of the pandemic in the first interview or the reaction to the specific restrictions that were introduced.

The interviews were conducted by 5 female interviewers with experience in moderating qualitative interviews, all with a psychological background. After each series of interviews, all the members of the research teams took part in debriefing sessions, which consisted of discussing the information obtained from each respondent, exchanging general conclusions, deciding about the topics for the following interview stage, and adjusting them to the pandemic situation in the country.

Data analysis.

All the interviews were transcribed in Polish by the moderators and then double-checked (each moderator transcribed the interviews of another moderator, and then the interviewer checked the accuracy of the transcription). The whole process of analysis was conducted on the material in Polish (the native language of the authors of the study and respondents). The final page count of the transcript is approximately 1800 pages of text. The results presented below are only a portion of the total data collected during the interviews. While there are about 250 pages of the transcription directly related to the topic of the article, due to the fact that the interview was partly free-form, some themes merge with others and it is not possible to determine the exact number of pages devoted exclusively to analysis related to the topic of the article. Full dataset can be found in S1 Dataset .

Data was then processed into thematic analysis, which is defined as a method of developing qualitative data consisting of the identification, analysis, and description of the thematic areas [ 35 ]. In this type of analysis, a thematic unit is treated as an element related to the research problem that includes an important aspect of data. An important advantage of thematic analysis is its flexibility, which allows for the adoption of the most appropriate research strategy to the phenomenon under analysis. An inductive approach was used to avoid conceptual tunnel vision. Extracting themes from the raw data using an inductive approach precludes the researcher from imposing a predetermined outcome.

As a first step, each moderator reviewed the transcripts of the interviews they had conducted. Each transcript was thematically coded individually from this point during the second and the third reading. In the next step, one of the researchers reviewed the codes extracted by the other members of the research team. Then she made initial interpretations by generating themes that captured the essence of the previously identified codes. The researcher created a list of common themes present in all of the interviews. In the next step, the extracted themes were discussed again with all the moderators conducting the coding in order to achieve consistency. This collaborative process was repeated several times during the analysis. Here, further superordinate (challenges of COVID-19 pandemic) and subordinate (ways of dealing with challenges) themes were created, often by collapsing others together, and each theme listed under a superordinate and subordinate category was checked to ensure they were accurately represented. Through this process of repeated analysis and discussion of emerging themes, it was possible to agree on the final themes that are described below.

Main challenges of the COVID-19 pandemic.

Challenge 1 –limitation of direct contact with people . The first major challenge of the pandemic was that direct contact with other people was significantly reduced. The lockdown forced many people to work from home and limit contact not only with friends but also with close family (parents, children, and siblings). Limiting contact with other people was a big challenge for most of our respondents, especially those who were living alone and for those who previously led an active social life. Depending on their earlier lifestyle profile, for some, the bigger problem was the limitation of contact with the family, for others with friends, and for still others with co-workers.

I think that because I can’t meet up with anyone and that I’m not in a relationship , I miss having sex , and I think it will become even more difficult because it will be increasingly hard to meet anyone . (5 . 3_ M_39_single) . The number In the brackets at the end of the quotes marks the respondent’s number (according to Table 1 ) and the stage of the interview (after the dash), further is information about gender (F/M), age of the respondent and family status. Linguistic errors in the quotes reflect the spoken language of the respondents.

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Changes over time . Over the course of the 6 months of the study, an evolution in the attitudes to the restriction of face-to-face contact could be seen: from full acceptance, to later questioning its rationale. Initially (March and April), almost all the respondents understood the reasons for the isolation and were compliant. At the beginning, people were afraid of the unknown COVID-19. They were concerned that the tragic situation from Italy, which was intensively covered in the media, could repeat itself in Poland (stage 1–2 of the study). However, with time, the isolation started to bother them more and more, and they started to look for solutions to bypass the isolation guidelines (stage 3–4), both real (simply meeting each other) and mental (treating isolation only as a guideline and not as an order, perceiving the family as being less threatening than acquaintances or strangers in a store). The turning point was the long May weekend that, due to two public holidays (1 st and 3 rd May), has for many years been used as an opportunity to go away with family or friends. Many people broke their voluntary isolation during that time encouraged by information about the coming loosening of restrictions.

During the summer (stage 5 of the survey), practically no one was fully compliant with the isolation recommendations anymore. At that time, a growing familiarity could be observed with COVID-19 and an increasing tendency to talk about it as “one of many diseases”, and to convince oneself that one is not at risk and that COVID-19 is no more threatening than other viruses. Only a small group of people consciously failed to comply with the restrictions of contact with others from the very beginning of the pandemic. This behavior was mostly observed among people who were generally less anxious and less afraid of COVID-19.

I’ve had enough. I’ve had it with sitting at home. Okay, there’s some kind of virus, it’s as though it’s out there somewhere; it’s like I know 2 people who were infected but they’re still alive, nothing bad has happened to anyone. It’s just a tiny portion of people who are dying. And is it really such a tragedy that we have to be locked up at home? Surely there’s an alternative agenda there? (17.4_F_35_Adult and child)

Ways of dealing . In the initial phase, when almost everyone accepted this restriction and submitted to it, the use of communication platforms for social meetings increased (see Ways of dealing with challenges in Table 1 ) . Meetings on communication platforms were seen as an equivalent of the previous face-to-face contact and were often even accompanied by eating or drinking alcohol together. However, over time (at around stage 4–5 of the study) people began to feel that such contact was an insufficient substitute for face-to-face meetings and interest in online meetings began to wane. During this time, however, an interesting phenomenon could be seen, namely, that for many people the family was seen as a safer environment than friends, and definitely safer than strangers. The belief was that family members would be honest about being sick, while strangers not necessarily, and—on an unconscious level—the feeling was that the “family is safe”, and the “family can’t hurt them”.

When it became clear that online communication is an insufficient substitute for face-to-face contacts, people started to meet up in real life. However, a change in many behaviors associated with meeting people is clearly visible, e.g.: refraining from shaking hands, refraining from cheek kissing to greet one another, and keeping a distance during a conversation.

I can’t really say that I could ‘feel’ Good Friday or Holy Saturday. On Sunday, we had breakfast together with my husband’s family and his sister. We were in three different places but we connected over Skype. Later, at noon, we had some coffee with my parents, also over Skype. It’s obvious though that this doesn’t replace face-to-face contact but it’s always some form of conversation. (9.3_F_25_Couple, no children)

Challenge 2 –restrictions on movement and travel . In contrast to the restrictions on contact with other people, the restrictions on movement and the closing of borders were perceived more negatively and posed bigger challenges for some people (especially those who used to do a lot of travelling). In this case, it was less clear why these regulations were introduced (especially travel restrictions within the country). Moreover, travel restrictions, particularly in the case of international travels, were associated with a limitation of civil liberties. The limitation (or complete ban) on travelling abroad in the Polish situation evoked additional connotations with the communist times, that is, with the fact that there was no freedom of movement for Polish citizens (associations with totalitarianism and dictatorship). Interestingly, the lack of acceptance of this restriction was also manifested by people who did not travel much. Thus, it was not just a question of restricting travelling abroad but more of restricting the potential opportunity (“even if I’m not planning on going anywhere, I know I still can”).

Limitations on travelling around the country were particularly negatively felt by families with children, where parents believe that regular exercise and outings are necessary for the proper development of their children. For parents, it was problematic to accept the prohibition of leaving the house and going to the playground (which remained closed until mid-May). Being outdoors was perceived as important for maintaining immunity (exercise as part of a healthy lifestyle), therefore, people could not understand the reason underlying this restriction and, as a consequence, often did not accept it.

I was really bothered by the very awareness that I can’t just jump in my car or get on a plane whenever I want and go wherever I want. It’s not something that I have to do on a daily basis but freedom of movement and travelling are very important for me. (14.2_M_55_Two adults and children)

Changes over time . The travel and movement limitations, although objectively less severe for most people, aroused much greater anger than the restrictions on social contact. This was probably due to a greater sense of misunderstanding as to why these rules were being introduced in the first place. Moreover, they were often communicated inconsistently and chaotically (e.g., a ban on entering forests was introduced while, at the same time, shopping malls remained open and masses were allowed to attend church services). This anger grew over time—from interview to interview, the respondents’ irritation and lack of acceptance of this was evident (culminating in the 3 rd -4 th stage of the study). The limitation of mobility was also often associated with negative consequences for both health and the economy. Many people are convinced that being in the open air (especially accompanied by physical activity) strengthens immunity, therefore, limiting such activity may have negative health consequences. Some respondents pointed out that restricting travelling, the use of hotels and restaurants, especially during the holiday season, will have serious consequences for the existence of the tourism industry.

I can’t say I completely agree with these limitations because it’s treating everything selectively. It’s like the shopping mall is closed, I can’t buy any shoes but I can go to a home improvement store and buy some wallpaper for myself. So I don’t see the difference between encountering people in a home improvement store and a shopping mall. (18.2_F_48_Two adults and children)

Ways of dealing . Since the restriction of movement and travel was more often associated with pleasure-related behaviors than with activities necessary for living, the compensations for these restrictions were usually also from the area of hedonistic behaviors. In the statements of our respondents, terms such as “indulging” or “rewarding oneself” appeared, and behaviors such as throwing small parties at home, buying better alcohol, sweets, and new clothes were observed. There were also increased shopping behaviors related to hobbies (sometimes hobbies that could not be pursued at the given time)–a kind of “post-pandemic” shopping spree (e.g., a new bike or new skis).

Again, the reaction to this restriction also depended on the level of fear of the COVID-19 disease. People who were more afraid of being infected accepted these restrictions more easily as it gave them the feeling that they were doing something constructive to protect themselves from the infection. Conversely, people with less fears and concerns were more likely to rebel and break these bans and guidelines.

Another way of dealing with this challenge was making plans for interesting travel destinations for the post-pandemic period. This was especially salient in respondents with an active lifestyle in the past and especially visible during the 5 th stage of the study.

Today was the first day when I went to the store (due to being in quarantine after returning from abroad). I spent loads of money but I normally would have never spent so much on myself. I bought sweets and confectionery for Easter time, some Easter chocolates, too. I thought I’d do some more baking so I also bought some ingredients to do this. (1.2_ F_25_single)

Challenge 3 –necessary change in active lifestyle . Many of the limitations related to COVID-19 were a challenge for people with an active lifestyle who would regularly go to the cinema, theater, and gym, use restaurants, and do a lot of travelling. For those people, the time of the COVID constraints has brought about huge changes in their lifestyle. Most of their activities were drastically restricted overnight and they suddenly became domesticated by force, especially when it was additionally accompanied by a transition to remote work.

Compulsory spending time at home also had serious consequences for people with school-aged children who had to confront themselves with the distance learning situation of their children. The second challenge for families with children was also finding (or helping find) activities for their children to do in their free time without leaving the house.

I would love to go to a restaurant somewhere. We order food from the restaurant at least once a week, but I’d love to go to the restaurant. Spending time there is a different way of functioning. It is enjoyable and that is what I miss. I would also go to the cinema, to the theater. (13.3_M_46_Two adults and child.)

Changes over time . The nuisance of restrictions connected to an active lifestyle depended on the level of restrictions in place at a given time and the extent to which a given activity could be replaced by an alternative. Moreover, the response to these restrictions depended more on the individual differences in lifestyle rather than on the stage of the interview (except for the very beginning, when the changes in lifestyle and everyday activities were very sudden).

I miss that these restaurants are not open . And it’s not even that I would like to eat something specific . It is in all of this that I miss such freedom the most . It bothers me that I have no freedom . And I am able to get used to it , I can cook at home , I can order from home . But I just wish I had a choice . (2 . 6_F_27_single ).

Ways of dealing . In the initial phase of the pandemic (March-April—stage 1–3 of the study), when most people were afraid of the coronavirus, the acceptance of the restrictions was high. At the same time, efforts were made to find activities that could replace existing ones. Going to the gym was replaced by online exercise, and going to the cinema or theater by intensive use of streaming platforms. In the subsequent stages of the study, however, the respondents’ fatigue with these “substitutes” was noticeable. It was then that more irritation and greater non-acceptance of certain restrictions began to appear. On the other hand, the changes or restrictions introduced during the later stages of the pandemic were less sudden than the initial ones, so they were often easier to get used to.

I bought a small bike and even before that we ordered some resistance bands to work out at home, which replace certain gym equipment and devices. […] I’m considering learning a language. From the other online things, my girlfriend is having yoga classes, for instance. (7.2_M_28_Couple, no children)

Challenge 4 –boredom , monotony . As has already been shown, for many people, the beginning of the pandemic was a huge change in lifestyle, an absence of activities, and a resulting slowdown. It was sometimes associated with a feeling of weariness, monotony, and even of boredom, especially for people who worked remotely, whose days began to be similar to each other and whose working time merged with free time, weekdays with the weekends, and free time could not be filled with previous activities.

In some way, boredom. I can’t concentrate on what I’m reading. I’m trying to motivate myself to do such things as learning a language because I have so much time on my hands, or to do exercises. I don’t have this balance that I’m actually doing something for myself, like reading, working out, but also that I’m meeting up with friends. This balance has gone, so I’ve started to get bored with many things. Yesterday I felt that I was bored and something should start happening. (…) After some time, this lack of events and meetings leads to such immense boredom. (1.5_F_25_single)

Changes over time . The feeling of monotony and boredom was especially visible in stage 1 and 2 of the study when the lockdown was most restrictive and people were knocked out of their daily routines. As the pandemic continued, boredom was often replaced by irritation in some, and by stagnation in others (visible in stages 3 and 4 of the study) while, at the same time, enthusiasm for taking up new activities was waning. As most people were realizing that the pandemic was not going to end any time soon, a gradual adaptation to the new lifestyle (slower and less active) and the special pandemic demands (especially seen in stage 5 and 6 of the study) could be observed.

But I see that people around me , in fact , both family and friends , are slowly beginning to prepare themselves for more frequent stays at home . So actually more remote work , maybe everything will not be closed and we will not be locked in four walls , but this tendency towards isolation or self-isolation , such a deliberate one , appears . I guess we are used to the fact that it has to be this way . (15 . 6_M_43_Two adults and child) .

Ways of dealing . The answer to the monotony of everyday life and to finding different ways of separating work from free time was to stick to certain rituals, such as “getting dressed for work”, even when work was only by a computer at home or, if possible, setting a fixed meal time when the whole family would gather together. For some, the time of the beginning of the pandemic was treated as an extra vacation. This was especially true of people who could not carry out their work during the time of the most severe restrictions (e.g., hairdressers and doctors). For them, provided that they believed that everything would return to normal and that they would soon go back to work, a “vacation mode” was activated wherein they would sleep longer, watch a lot of movies, read books, and generally do pleasant things for which they previously had no time and which they could now enjoy without feeling guilty. Another way of dealing with the monotony and transition to a slower lifestyle was taking up various activities for which there was no time before, such as baking bread at home and cooking fancy dishes.

I generally do have a set schedule. I begin work at eight. Well, and what’s changed is that I can get up last minute, switch the computer on and be practically making my breakfast and coffee during this time. I do some work and then print out some materials for my younger daughter. You know, I have work till four, I keep on going up to the computer and checking my emails. (19.1_F_39_Two adults and children)

Challenge 5 –uncertainty about the future . Despite the difficulties arising from the circumstances and limitations described above, it seems that psychologically, the greatest challenge during a pandemic is the uncertainty of what will happen next. There was a lot of contradictory information in the media that caused a sense of confusion and heightened the feeling of anxiety.

I’m less bothered about the changes that were put in place and more about this concern about what will happen in the future. Right now, it’s like there’s these mood swings. […] Based on what’s going on, this will somehow affect every one of us. And that’s what I’m afraid of. The fact that someone will not survive and I have no way of knowing who this could be—whether it will be me or anyone else, or my dad, if somehow the coronavirus will sneak its way into our home. I simply don’t know. I’m simply afraid of this. (10.1_F_55_Couple, no children)

Changes over time . In the first phase of the pandemic (interviews 1–3), most people felt a strong sense of not being in control of the situation and of their own lives. Not only did the consequences of the pandemic include a change in lifestyle but also, very often, the suspension of plans altogether. In addition, many people felt a strong fear of the future, about what would happen, and even a sense of threat to their own or their loved ones’ lives. Gradually (interview 4), alongside anxiety, anger began to emerge about not knowing what would happen next. At the beginning of the summer (stage 5 of the study), most people had a hope of the pandemic soon ending. It was a period of easing restrictions and of opening up the economy. Life was starting to look more and more like it did before the pandemic, fleetingly giving an illusion that the end of the pandemic was “in sight” and the vision of a return to normal life. Unfortunately, autumn showed that more waves of the pandemic were approaching. In the interviews of the 6 th stage of the study, we could see more and more confusion and uncertainty, a loss of hope, and often a manifestation of disagreement with the restrictions that were introduced.

This is making me sad and angry. More angry, in fact. […] I don’t know what I should do. Up until now, there was nothing like this. Up until now, I was pretty certain of what I was doing in all the decisions I was making. (14.4_M_55_Two adults and children)

Ways of dealing . People reacted differently to the described feeling of insecurity. In order to reduce the emerging fears, some people searched (sometimes even compulsively) for any information that could help them “take control” of the situation. These people searched various sources, for example, information on the number of infected persons and the number of deaths. This knowledge gave them the illusion of control and helped them to somewhat reduce the anxiety evoked by the pandemic. The behavior of this group was often accompanied by very strict adherence to all guidelines and restrictions (e.g., frequent hand sanitization, wearing a face mask, and avoiding contact with others). This behavior increased the sense of control over the situation in these people.

A completely opposite strategy to reducing the feeling of uncertainty which we also observed in some respondents was cutting off information in the media about the scale of the disease and the resulting restrictions. These people, unable to keep up with the changing information and often inconsistent messages, in order to maintain cognitive coherence tried to cut off the media as much as possible, assuming that even if something really significant had happened, they would still find out.

I want to keep up to date with the current affairs. Even if it is an hour a day. How is the pandemic situation developing—is it increasing or decreasing. There’s a bit of propaganda there because I know that when they’re saying that they have the situation under control, they can’t control it anyway. Anyhow, it still has a somewhat calming effect that it’s dying down over here and that things aren’t that bad. And, apart from this, I listen to the news concerning restrictions, what we can and can’t do. (3.1_F_54_single)

Discussion and conclusions

The results of our study showed that the five greatest challenges resulting from the COVID-19 pandemic are: limitations of direct contact with people, restrictions on movement and travel, change in active lifestyle, boredom and monotony, and finally uncertainty about the future. As we can see the spectrum of problems resulting from the pandemic is very wide and some of them have an impact on everyday functioning and lifestyle, some other influence psychological functioning and well-being. Moreover, different people deal with these problems differently and different changes in everyday life are challenging for them. The first challenge of the pandemic COVID-19 problem is the consequence of the limitation of direct contact with others. This regulation has very strong psychological consequences in the sense of loneliness and lack of closeness. Initially, people tried to deal with this limitation through the use of internet communicators. It turned out, however, that this form of contact for the majority of people was definitely insufficient and feelings of deprivation quickly increased. As much data from psychological literature shows, contact with others can have great psychological healing properties [e.g., 29 ]. The need for closeness is a natural need in times of crisis and catastrophes [ 30 ]. Unfortunately, during the COVID-19 pandemic, the ability to meet this need was severely limited by regulations. This led to many people having serious problems with maintaining a good psychological condition.

Another troubling limitation found in our study were the restrictions on movement and travel, and the associated restrictions of most activities, which caused a huge change in lifestyle for many people. As shown in previous studies, travel and diverse leisure activities are important predictors of greater well-being [ 36 ]. Moreover, COVID-19 pandemic movement restrictions may be perceived by some people as a threat to human rights [ 37 ], which can contribute to people’s reluctance to accept lockdown rules.

The problem with accepting these restrictions was also related to the lack of understanding of the reasons behind them. Just as the limitation in contact with other people seemed understandable, the limitations related to physical activity and mobility were less so. Because of these limitations many people lost a sense of understanding of the rules and restrictions being imposed. Inconsistent communication in the media—called by some researchers the ‘infodemic’ [ 18 ], as well as discordant recommendations in different countries, causing an increasing sense of confusion in people.

Another huge challenge posed by the current pandemic is the feeling of uncertainty about the future. This feeling is caused by constant changes in the rules concerning daily functioning during the pandemic and what is prohibited and what is allowed. People lose their sense of being in control of the situation. From the psychological point of view, a long-lasting experience of lack of control can cause so-called learned helplessness, a permanent feeling of having no influence over the situation and no possibility of changing it [ 38 ], which can even result in depression and lower mental and physical wellbeing [ 39 ]. Control over live and the feeling that people have an influence on what happens in their lives is one of the basic rules of crisis situation resilience [ 30 ]. Unfortunately, also in this area, people have huge deficits caused by the pandemic. The obtained results are coherent with previous studies regarding the strategies harnessed to cope with the pandemic [e.g., 5 , 10 , 28 , 33 ]. For example, some studies showed that seeking social support is one of the most common strategies used to deal with the coronavirus pandemic [ 33 , 40 ]. Other ways to deal with this situation include distraction, active coping, and a positive appraisal of the situation [ 41 ]. Furthermore, research has shown that simple coping behaviors such as a healthy diet, not reading too much COVID-19 news, following a daily routine, and spending time outdoors may be protective factors against anxiety and depressive symptoms in times of the coronavirus pandemic [ 41 ].

This study showed that the acceptance of various limitations, and especially the feeling of discomfort associated with them, depended on the person’s earlier lifestyle. The more active and socializing a person was, the more restrictions were burdensome for him/her. The second factor, more of a psychological nature, was the fear of developing COVID-19. In this case, people who were more afraid of getting sick were more likely to submit to the imposed restrictions that, paradoxically, did not reduce their anxiety, and sometimes even heightened it.

Limitations of the study.

While the study shows interesting results, it also has some limitations. The purpose of the study was primarily to capture the first response to problems resulting from a pandemic, and as such its design is not ideal. First, the study participants are not diverse as much as would be desirable. They are mostly college-educated and relatively well off, which may influence how they perceive the pandemic situation. Furthermore, the recruitment was done by searching among the further acquaintances of the people involved in the study, so there is a risk that all the people interviewed come from a similar background. It would be necessary to conduct a study that also describes the reaction of people who are already in a more difficult life situation before the pandemic starts.

Moreover, it would also be worthwhile to pay attention to the interviewers themselves. All of the moderators were female, and although gender effects on the quality of the interviews and differences between the establishment of relationships between women and men were not observed during the debriefing process, the topic of gender effects on the results of qualitative research is frequently addressed in the literature [ 42 , 43 ]. Although the researchers approached the process with reflexivity and self-criticism at all stages, it would have seemed important to involve male moderators in the study to capture any differences in relationship dynamics.

Practical implications.

The study presented has many practical implications. Decision-makers in the state can analyze the COVID-19 pandemic crisis in a way that avoids a critical situation involving other infectious diseases in the future. The results of our study showing the most disruptive effects of the pandemic on people can serve as a basis for developing strategies to deal with the effects of the crisis so that it does not translate into a deterioration of the public’s mental health in the future.

The results of our study can also provide guidance on how to communicate information about restrictions in the future so that they are accepted and respected (for example by giving rational explanations of the reasons for introducing particular restrictions). In addition, the results of our study can also be a source of guidance on how to deal with the limitations that may arise in a recurrent COVID-19 pandemic, as well as other emergencies that could come.

The analysis of the results showed that the COVID-19 pandemic, and especially the lockdown periods, are a particular challenge for many people due to reduced social contact. On the other hand, it is social contacts that are at the same time a way of a smoother transition of crises. This knowledge should prompt decision-makers to devise ways to ensure pandemic safety without drastically limiting social contacts and to create solutions that give people a sense of control (instead of depriving it of). Providing such solutions can reduce the psychological problems associated with a pandemic and help people to cope better with it.

Conclusions

As more and more is said about the fact that the COVID-19 pandemic may not end soon and that we are likely to face more waves of this disease and related lockdowns, it is very important to understand how the different restrictions are perceived, what difficulties they cause and what are the biggest challenges resulting from them. For example, an important element of accepting the restrictions is understanding their sources, i.e., what they result from, what they are supposed to prevent, and what consequences they have for the fight against the pandemic. Moreover, we observed that the more incomprehensible the order was, the more it provoked to break it. This means that not only medical treatment is extremely important in an effective fight against a pandemic, but also appropriate communication.

The results of our study showed also that certain restrictions cause emotional deficits (e.g., loneliness, loss of sense of control) and, consequently, may cause serious problems with psychological functioning. From this perspective, it seems extremely important to understand which restrictions are causing emotional problems and how they can be dealt with in order to reduce the psychological discomfort associated with them.

Supporting information

S1 table. a full description of the changes occurring in poland at the time of the study..

https://doi.org/10.1371/journal.pone.0258133.s001

S2 Table. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0258133.s002

S1 Dataset. Transcriptions from the interviews.

https://doi.org/10.1371/journal.pone.0258133.s003

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• 11. Fernandes N. Economic effects of coronavirus outbreak (COVID-19) on the world economy. IESE Business School Working Paper No. WP-1240-E. 2020 Mar 23.
• 15. ARC. Praca z domu w polskim wydaniu—badanie na zlecenie Gumtree.pl we współpracy z Randstat Polska [The Polish way of working from home—a study commissioned by Gumtree.pl in collaboration with Randstat Polska]. 2020 [cited 2021 Jun 1]. https://www.randstad.pl/strefa-pracownika/centrum-prasowe/badanie-gumtreepl-we-wspolpracy-z-randstad-potrafimy-sie-zorganizowac-choc-czasem-lubimy-sobie-poprzeszkadzac-praca-z-domu-w-polskim-wydaniu/
• 16. Sierpowska, I. O edukacji w czasie pandemii [On Education during pandemic]. Centrum Prasowe SWPS [Internet]. 2020 Sep 8. [cited 2021 Jun 1]. https://www.swps.pl/centrum-prasowe/informacje-prasowe/22390-o-edukacji-w-czasie-pandemii-2?dt=1622540060078
• 17. Polish Academy of Sciences. Understanding COVID-19. Report by the COVID-19 team at the President of the Polish Academy of Sciences. 2020 Sep 14. [Cited 2021 Jun 1]. https://informacje.pan.pl/images/2020/opracowanie-covid19-14-09-2020/ZrozumiecCovid19_opracowanie_PAN.pdf
• 25. Brown, K. The pandemic is not a natural disaster. The New Yorker [Internet]. 2020 Apr 13 [cited 2021 Jun 1]. https://www.newyorker.com/culture/annals-of-inquiry/the-pandemic-is-not-a-natural-disaster .
• 34. Maison D. Qualitative marketing research. Understanding consumer behaviour. London: Routledge; 2019.
• 36. Argyle M. Causes and correlates of happiness. In: Kahneman D, Diener E, Schwarz N, editors. Well-Being: The Foundations of Hedonic Psychology. New York: Russell Sage Foundation; 1999. p. 353–373.

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Coronavirus disease 2019 (COVID-19): A literature review

Affiliations.

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

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

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

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

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• COVID-19 pandemic and Internal Medicine Units in Italy: a precious effort on the front line. Montagnani A, Pieralli F, Gnerre P, Vertulli C, Manfellotto D; FADOI COVID-19 Observatory Group. Montagnani A, et al. Intern Emerg Med. 2020 Nov;15(8):1595-1597. doi: 10.1007/s11739-020-02454-5. Epub 2020 Jul 31. Intern Emerg Med. 2020. PMID: 32737837 Free PMC article. No abstract available.

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Home > Honors College > Honors Theses > 1912

Honors Theses

An analysis of the effects of covid-19 on students at the university of mississippi: family, careers, mental health.

Hannah Newbold Follow

Date of Award

Spring 5-1-2021

Document Type

Undergraduate Thesis

Integrated Marketing Communication

First Advisor

Second advisor.

Cynthia Joyce

Third Advisor

Marquita Smith

Relational Format

Dissertation/Thesis

This study analyzes the effects of COVID-19 on students at the University of Mississippi. For students, COVID-19 changed the landscape of education, with classes and jobs going online. Students who graduated in May 2020 entered a poor job market and many ended up going to graduate school instead of finding a job. Access to medical and professional help was limited at the very beginning, with offices not taking patients or moving appointments to virtual only. This would require that each student needing help had to have access to quality internet service, which wasn’t always guaranteed, thus producing additional challenges.

These chapters, including a robust literature review of relevant sources, as well as a personal essay, consist further of interviews with students and mental health counselors conducted over the span of several months. These interviews were conducted and recorded over Zoom. The interviews were conducted with individuals who traveled in similar social circles as me. These previously existing relationships allowed the conversation to go deeper than before and allowed new levels of relationship. Emerging from these conversations were six overlapping themes: the importance of family, the need for health over career, the challenge of isolation, struggles with virtual education, assessing mental health, and facing the reality of a bright future not promised. Their revelations of deep academic challenges and fears about the future amid stories of devastating personal loss, produces a striking and complex picture of emerging strength.

Recommended Citation

Newbold, Hannah, "An Analysis Of The Effects Of COVID-19 On Students At The University of Mississippi: Family, Careers, Mental Health" (2021). Honors Theses . 1912. https://egrove.olemiss.edu/hon_thesis/1912

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COVID-19 Thesis Impact Statement

The impact of the COVID-19 pandemic on all aspects of our lives is well known.

Victoria experienced six lockdowns between March 2020 and October 2021 that collectively totalled 262 days. Deakin University sought to mitigate this impact on the research by higher degree by research students in various ways, including providing priority access to laboratories and support to pivot research projects. Not all impact on research could be mitigated with direct and indirect effects of limited domestic and international travel, closed university campuses and restricted in-person access to human research participants.

Within this context, you have the option of describing the impact of COVID-19 on your research and how you modified your topic, methods and data collection due to COVID-19 restrictions. The COVID-19 Thesis Impact Statement aims to provide the examiners with a clearer understanding of how the research was affected and shaped due to COVID-19 disruptions.

A COVID-19 Thesis Impact Statement is not required and you may submit your thesis for examination without reference to the COVID-19 pandemic. Should you wish to submit your thesis with a COVID-19 Thesis Impact Statement, do so only under the advice of your supervisory panel.

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Following is some examples and advice of what and what not to include in your COVID-19 Thesis Impact Statement.

• How your planned research activities such as topic, research question, methods and data collection and/or the scope of your research were disrupted or changed due the pandemic. For instance: inability to conduct fieldwork or face-to-face research; access to facilities such as labs, archives or other working spaces; inability to collect or analyse data due to travel restrictions.
• How the research was shaped by the disruption: the actions or decisions taken to mitigate the disruption; new focus; revised research questions or development; pivoting or adjusting the research project.
• Any other relevant factors relating to the impact of the COVID-19 disruption on your research.
• Ensure that you do not infer that your thesis is of a lower standard due to the effects of the COVID-19 pandemic.
• Your COVID-19 Thesis Impact Statement should not address any effect on your personal circumstances.

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You may choose to include the statement as an upfront additional page in your thesis and/or address the impact within the content of the thesis.

If placed as a separate page at the beginning of your thesis, it should be no more than 600 words.

We encourage you to discuss with your supervisor the format of a COVID-19 Thesis Impact Statement that best fits your thesis and impact on your research.

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Department of Ecology & Evolutionary Biology

A senior thesis that turned the challenges of covid-19 into an advantage.

Undergraduate senior Kuziel and Professor Pringle settled on a thesis that turned the challenges of COVID-19 into an advantage: since he couldn’t gather his own data at one national park, he would use previously gathered samples from six animal species — baboons, warthogs, kudu, hartebeest, impala and zebra — at six national parks — Gorongosa in Mozambique, Mpala in Kenya, Kafue National Park in Zambia, Serengeti National Park in Tanzania, Niassa National Reserve in Mozambique and Nyika National Park in Malawi — to investigate the fungi found in the animals’ intestines.

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• Published: 23 September 2024

Effect of silver nanoparticles and REP-PCR typing of Staphylococcus aureus isolated from various sources

• Eman M. Elghazaly   ORCID: orcid.org/0000-0002-7993-971X 1 ,
• Helmy A. Torky 2 &
• Rasha Gomaa Tawfik 2  

Scientific Reports volume  14 , Article number:  21997 ( 2024 ) Cite this article

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• Microbiology
• Molecular biology

This is the primary study at Matrouh Governorate to unveil antibiotic resistance, biofilm formation, silver nanoparticles (Ag-NPs) effect using electron microscopy, and REP-PCR analysis of Staphylococcus aureus strains isolated from COVID-19 patients, contaminated food, and Morel’s diseased sheep and goats. A total of 15 S. aureus strains were isolated; five from each of the COVID-19 patients, Morel's diseased sheep and goats, and contaminated food. All strains were considered multidrug-resistant (MDR). All strains showed the presence of biofilm. Morphological changes in the cell surface of the bacterium were evidenced, and penetration with the rupture of some bacterial cells. Based on REP-PCR analysis, 4 clusters (C1-C4) with dissimilarity between clusters C1 and C2 8% and between C3 and C4 15%. Cluster I included 3 strains from contaminated food with a similarity of 97%, and Cluster II included 2 strains from contaminated food and 2 from COVID-19-infected patients with a similarity of 96% (confirming the zoonotic nature of this pathogen). Cluster III contained 4 strains isolated from Morel's diseased sheep & goats with a similarity ratio of 99% in comparison the 4th cluster contained 3 strains isolated from COVID-patients and one from Morel's diseased sheep & goats with a similarity ratio of 92%.

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Introduction.

S. aureus is one of the most important opportunistic pathogens due to its high pathogenicity, high contamination rate for food, rapid transmission, and rapid distribution. This universal microorganism is carried asymptomatically in 20–30% of the human population 1 and is a risk factor for subsequent infection 2 . The bacterium can cause minor skin lesions to invasive lesions such as pneumonia and endocarditis. The severity of the disease is linked to a battery of virulence factors—more than 70 genes related to its pathogenicity and invasiveness 3 .

Extracellular toxins including Staphylococcus enterotoxins (SEs) genes responsible for food poisoning outbreaks 4 . Some of its toxins are linked with an increased death rate among hosts suffering from other diseases. Alpha hemolysin is present in all S. aureus strains as the major virulence factor linked with mammary gland necrosis and a higher death rate among infected animals 5 . Contamination of food by methicillin-resistant S. aureus (MRSA) strains with a wide range of exotoxins, including enterotoxins confer life-threatening traits on MRSA, thereby making treatment complicated 6 .

The global pandemic illness COVID-19 caused by SARS-CoV-2, also known as COVID-19 by the World Health Organization (WHO) 7 , is characterized by severe acute respiratory syndrome. Today the management for the prevention and control of the disease allows the utilization of vaccines approved by the Food Drug Administration (FDA). Deaths accompanied by respiratory syndrome, endocarditis, and pneumonia draw attention that S. aureus may display as a relapse infection by strains responsible for the index case 2 virulent factors and enterotoxins and production of other toxins inhibit the immune response as alarming 8 .

The resistance of S. aureus is acquired soon after exposure to treatment with antibiotic 9 through the acquisition of antibiotics resistance agents, mobile molecular elements such as integrons, and the existence of biofilm. antibiotic resistance poses a threat to food safety and leads to the death of animals 10 .

The mortality of S. aureus infections has dramatically increased as a result of the rise of MRSA strains, bringing attention to the requirement for the creation of novel therapeutic and preventive measures such as metallic nanoparticles, exclusively Ag-NPs to counteract multidrug-resistant S. aureus 11 . Even though 12 , are convinced that nanoparticles are essential in treatment besides systemic antibiotics to evade colonization of bacteria and possibly septicemia in the clinic; even though its mechanism is not fully known 13 .

Ag-NPs are seen as a good option among nanoparticles with marked antibacterial profiles, relatively inexpensive to produce 14 . Nanotechnology has potential use in human and veterinary medicine 15 . It is not surprising to see nanotechnology being employed to tackle the danger of antibiotic resistance because this technology is increasingly being used in medicine. Nanoparticles can be applied in several ways to cure illnesses 16 .

Repetitive element sequences spread throughout the chromosome of all bacteria and Van Der Zee et al. 17 suggested REP-PCR genotyping technique based on the presence of homologous Mycoplasma pneumonia repeat-like elements in S. aureus for tracing the source of infection. Monitoring the prevalence of nosocomial Staphylococcus infections is simple and quick. MRSA isolates linked to outbreaks were discovered to share a cluster of identical REP-PCR profiles 17 , 18 . Manga and Vyletelova 19 mentioned its higher discriminatory power and reproducibility than RAPD and PFGE.

The main objectives of this research are studying the antibiotics resistance pattern of S. aureus isolates, evaluating the effect of silver nanoparticles on pan-drug resistant S. aureus strains by electron microscopy and determining the genetic relatedness among S. aureus strains isolated from COVID-19 patients, contaminated food and Morel's diseased sheep and goat by REP-PCR at Matrouh Governorate.

Out of 215 samples (120 contaminated food samples, 65 Morel's diseased sheep, and goats samples, and 30 samples from COVID-19 patients), 15 (7%) S. aureus strains were recovered, 5 (16.7%) from COVID-19 patients, 5 (7.7%) from Morel's diseased sheep and goats, and 5 (4.2%) from contaminated food as shown in Table 1 . Staphylococcus enterotoxin a (sea) was found in four isolates from Morel's diseased sheep and goats, three isolates from the COVID-19 patients had the Staphylococcus enterotoxin b (seb) gene, and only one isolate from contaminated food had the seb gene. All strains displayed tolerance to at least three classes of antibiotics. Most strains showed MDR, and only 1(6.67%) of them was Pan-drug resistant (PDR) (showed resistance to six classes of antibiotics) as shown in Tables 2 , 3 and all 15 (100%) strains were biofilm producers (6 weak, 4 moderate, and 5 strong) as shown in Table 2 , the most pan-drug resistant strain that showed resistance to different six classes of antibiotics also, showed the presence of integron1 (this strain was used for evaluating the effect of silver nanoparticles by electron microscopy).

The disc diffusion of Ag-NPs revealed that 100 µg/ml is the minimum bactericidal concentration (MBC) required to inhibit cells of the S. aureus strain that exhibited resistance to six classes of antibiotics (pan-drug resistant). The minimum inhibitory concentration (MIC) was 50 µg/ml. The diffusion plate results revealed a strong positive correlation between the concentration of Ag-NPs and antibacterial efficacy, as measured by the zones of inhibition; increasing Ag-NPs concentrations increases the antibacterial efficacy as shown in Table 4 and Fig.  1 . The silver nanoparticles (Ag-NPs) used were spherical (Fig.  2 ). As shown in Fig.  3 , the images produced by the presence of Ag-NPs at concentrations of 100 µg/ml and various exposure times of 2.5, 10, and 25 min indicate changes in the integrity of the outer bacterial cell membrane and a strong positive correlation was found between the duration of exposure to silver nanoparticles and the morphological changes in bacterial cells that determined by SEM (Fig.  4 ) and Table 5 , as the effect was more pronounced where the concentration was 100 µg/ml with a 25- min exposure time as shown in Fig.  3 D.

Correlation between silver nanoparticles concentration and antibacterial efficacy.

SEM micrograph of spherical Ag-NPs particles and with an 18.7 nm average size.

Effect of silver nanoparticles on isolated S. aureus . ( A ) The surface of untreated S. aureus cells was smooth and retained their coccus/round morphology. ( B ) S. aureus cells treated with 100 µg/ml Ag-NPs for 2.5 min appeared to undergo slight lysis. ( C ) S. aureus treated with 100 µg/ml Ag-NPs for 10 min appeared to undergo moderate lysis ( D ) S. aureus treated with 100 µg/ml Ag-NPs for 25 min appeared to undergo severe lysis, so the contents of the cell were released into the cytoplasm.

Correlation between duration of exposure to silver nanoparticles and morphological changes in bacterial cells that detected by SEM.

REP-PCR analysis revealed the presence of 4 clusters and 3 single strains (11, 8, and 5); cluster I included two strains (13 and 15) recovered from contaminated food and a single strain (11) which also, recovered from contaminated food with a similarity ratio about 97% between them, cluster II included 3 strains (12, 14, 10), two of them (12 and 14) recovered from contaminated food and one of them (10) recovered from COVID-19 patients and a single strain (8) that recovered from COVID-19 patients with a similarity ratio about 96%, cluster III which contained 4 strains (1, 2, 3, 4) recovered from Morel's diseased sheep and goats with a similarity ratio about 99% and cluster IV which contained 3 strains recovered from COVID-19 patients (6, 7, 9) and a single strain (5) which recovered from Morel's diseased sheep and goats with a similarity ratio about 92%, the dissimilarity between cluster I (CI) and C II about 8%, but the difference between C III and C IV about 15% as shown in Figs.  5 , 6 and Table 6 .

REP-PCR of S. aureus . REP-PCR assay of S. aureus strains from different sources in 1.5% agarose gel, L: 100 bp molecular marker, lanes (1–5): S. aureus isolates from Morel's diseased sheep and goat origin, lanes (6–10): S. aureus isolates from positive COVID -19 patient origin, Lanes (11–15): S. aureus isolates from contaminated food origin.

Cropped figure of dendrogram showing the genetic relatedness among 15 S. aureus isolates using Ward linkage, (1, 2, 3, 4 and 5): S. aureus isolates from Morel's diseased sheep and goat origin, (6, 7, 8, 9 and 10): S. aureus isolates from positive COVID-19 patient origin, (11, 12, 13, 14 and 15): S. aureus isolates from contaminated food origin.

S. aureus , a symptomatically colonizing normal flora of the skin and nasopharynx of animals and humans, characterized by its pathogenicity for both 20 causes skin infection, pneumonia, and endocarditis in humans 21 .

In this study, we isolated and identified phenotypically and genotypically 15 S. aureus strains out of 215 different samples: five from each of the COVID-19 patients, Morel's diseased sheep and goats, and contaminated food samples.

Enterotoxin not only suppresses the immune system 8 but also increases the risk of a chronic infection 11 and is linked to the virulence and pathogenicity of strains 22 , 23 . Treatment becomes more difficult when any kind of SE acts as a superantigen on polymorphonuclear cells, causing the production of the IL-4 and IL-10 genes and then stimulating Th2 cells 24 . This makes it more difficult to eradicate invasive infections, which can cause serious lung damage in people with cystic fibrosis 25 and lead to 94,000 invasive diseases and over 18,000 deaths each year in the United States 26 . Every year, 150,000 MRSA infections occur in Europe, and 7000 deaths are associated with these infections 27 .

Most isolated strains have one of the SEs. MRSA is the leading bacterium causing food poisoning outbreaks and is regarded as the most prevalent pathogen in human nosocomial infections 28 . 14 (41.2%) of the 34 S. aureus isolates were positive for Staphylococcus enterotoxin B (SEB) 29 .

In this study, all 15 S. aureus strains showed resistance to at least three different classes of antibiotics. Researchers determined that 24%, 47%, 91%, 82%, 59%, and 47% of S. aureus isolates were resistant to several antibiotics, indicating MDR 29 . All S. aureus strains showed different resistance standards to antibiotics 30 , while most of them were MDR that resist penicillins and their derivatives and methicillin, and many of the most frequently recommended beta-lactam antibiotics, comprising amoxicillin and oxacillin, match what is known as MRSA 31 .

All strains (100%) were biofilm producers. Neopane et al. 32 found that 86.7% of biofilm-producing S. aureus exhibited MDR. Moreover, only one isolate showed the presence of integron 1 (the one that showed resistance to six classes of antibiotics). The class 1 integron gene cassette with variable amplicon and the integrase gene (intl1) were found to be present in 42% and 36% of the isolates, respectively 33 . The presence of integron contributes to the transfer of antibiotic-resistance genes among Staphylococci 34 .

The condition is exacerbated if contaminated food of animal origin (milk, meat) with S. aureus is submitted to patients in poor health 35 , 36 , 37 , which leads to subsequent dissemination of resistance to humans from the food chain, increasing the difficulty of treatment infection in humans and decreasing possible therapeutic uses 20 .

The emergence of resistance to antibiotics that are either not licensed for use in animals or that are listed for use in humans only complicates the issue of antimicrobial resistance in low-source countries like Egypt 38 . Most developed nations have antimicrobial drug resistance (AMR) surveillance and monitoring systems that are routinely updated 7 , as the Danish Integrated Antimicrobial Resistance, Monitoring, and Research Programme in Denmark and the National Antimicrobial Resistance Monitoring Systems (NARMS) in the United States. As a result, these nations have detailed maps of the AMR phenomenon 39 . Alternatively, due to a lack of surveillance networks, laboratory capacity, and proper diagnosis, and consequently, a lack of information, there is no regular surveillance or monitoring system for MDR in developing nations in Africa 40 .

The utilization of metallic nanoparticles that show antimicrobial activities is one of the recent techniques to overcome microbes and multi-drug resistant bacteria 41 . In our investigation, silver nanoparticles (Ag NPs) inhibited the growth of strong biofilm-forming and pan-drug-resistant S. aureus . In disc diffusion tests, the increase in the concentration of Ag-NPs increases the antibacterial efficacy; this relation was noticed by Armanullah et al. 42 in Gram–negative bacteria. There is a direct relation between the duration of exposure to silver nanoparticles and its effect on the microorganisms, as found by Li et al. 43 who reported that the exposure of S. aureus cells to 50 g/ml Ag-NPs for 6 h caused the DNA to become condensed and lose its capacity for replication, while its exposure to 50 g/ml Ag-NPs for 12 h caused the cell wall to break down, allowing the contents of the cells to leak out into the environment. Eventually, the cell wall disintegrated. The enzymatic activity of respiratory chain dehydrogenase may lso be decreased by Ag-NPs due to the low diffusibility of engineered nanoparticles (ENP). The efficacy of disc diffusion susceptibility assays for evaluating their antibacterial activity is in doubt, but Kourmouli et al. 44 proved that their penetration through the cultured media and Ag-NPs' unique size-dependent properties are not responsible for their antibacterial diffusion behavior, which is instead ascribed to the ions they release.

The mechanisms of Ag NPs' action are blurred and unclear. The exact mechanisms are not completely understood. According to Duran et al. 13 and Abdelrehiem et al. 45 , Ag-NPs may interact with the bacterial cell wall, produce reactive oxygen species (ROS), interact with DNA, and release Ag + ions 41 . According to Qing et al. 46 , dissolving Ag + ions produced during the oxidation and dilution of Ag-NPs in an aqueous solution and their subsequent reaction with cell membrane proteins are what cause the morphological changes seen in bacteria exposed to Ag-NPs 47 , reported that nanoparticles may be able to interact with the cell wall of bacteria by changing lipopolysaccharide and making pores that alter the cell membrane while Vazquez-Munoz et al. 48 attributed its action to the direct influence of silver on membrane stability, an anchor to the bacterial cell wall, allow Ag-NPs to penetrate the intracellular environment that achieves to enter the cell cytoplasm and release Ag + that can interact with various biomolecules ended by bacterial death.

By using electron imQaging, we were able to demonstrate that Ag-NPs accumulated on the cell wall of S. aureus , penetrated the interior, and interacted with biomolecules, possibly causing the cell wall to rupture and/or bacterial death. In the twentieth century, people thought that silver was comparatively nanotoxic to mammalian cells, aside from the fact that it could lead to argyria. However, research has shown that silver-based compounds can be significantly toxic to human and animal cells at the nanoscale. These problems must be addressed before people hurry to indulge in the nanosilver boom 49 .

Finally, based on the results of REP-PCR as a recommended tool for partial fingerprinting analysis of 15 S. aureus strains, it revealed the presence of 4 clusters, gave detailed information to enable comparative analysis, confirmed the zoonotic nature of this important pathogen, and shared a common source, contamination, and/or infection. El-Gedawy et al. 50 reported that the four Rep-PCR primers generated roughly 55 fragments, of which 29 (52.5%) are considered to be polymorphic bands among S. aureus isolates and 26 (47.5%) are considered to be monomorphic bands. Holmes and Zadoks 34 provide evidence that humans are the primary natural carriers of S. aureus , which can contaminate food and put customers at risk for health problems. Shepheard et al. 51 reported that animal S. aureus strains are distinct from those infecting humans, and Manga and Vyletelova 19 , concluded that REP-PCR is good compared to RAPD and PFGE, the pulsed-field gel electrophoresis screening of 42 S. aureus strains yielded six clusters. Abdelrahman 52 subtyped 12 strains of S. aureus (10 from ruminants and 2 from poultry) at 75% genetic similarity into 6 ERIC-types (A1:A3, B1:B3). Holmes and Zadoks 34 attributed the diversity to random nuc leotide mutations and horizontal gene transfer.

In conclusion, the powerful biofilm-forming and antibiotic-resistant S. aureus strain development is inhibited by Ag-NPs. There is a direct relationship between the concentration and the antibacterial efficacy, as well as, between the duration of exposure to silver nanoparticles and their effect on the microorganisms. REP-PCR is one of the most effective methods to determine the genetic relatedness between different strains.

Material and methods

Sample size.

Two hundred and fifteen samples (120 contaminated food samples, 65 Morel's diseased sheep and goats samples, and 30 samples from COVID-19 patients) were collected from Matrouh Governorate for the isolation of S. aureus . By using the Epi Info sample size calculator, the odds ratio of contaminated food samples was 0.217 and the infection rate was 15%, so the minimum sample size was 106 contaminated food samples, the odds ratio of Morel's diseased sheep, and goats was 0.417 and the infection rate was 54%, so the minimum sample size was 56 Morel's diseased sheep and goats, the odds ratio of COVID-19 human was 0.200 and the infection rate was 22%, so the minimum sample size was 27 COVID-19 human cases 53 , 54 , 55 , so the minimum number required for doing our study was 189 samples. The odd ratios of different samples were illustrated in Table 7 .

Isolation of S . aureus

For the isolation of S. aureus , nasopharyngeal swab samples were taken from COVID-19 patients, Morel's diseased sheep, and goats 1 . Briefly, from clinical cases, cotton-tipped swabs moistened with sterile saline, rolling over the lesion surface five times, focusing on the area where there was evidence of pus or an inflamed area, and contaminated food samples were processed as recorded by Artursson et al., Wang et al. 56 , 57 . Using Mannitol salt agar (Oxoid), Baired- parker agar (Hi- media, Mumbai), and oxacillin resistance screening agar base plate (ORSAB) (Oxoid, UK) (it gives characteristic dense blue colonies) 58 .

Identification of S. aureus

Identification of S. aureus was carried out by microscopic examination, colonial characteristics, and biochemical identification: catalase-positive, coagulase-positive, and oxidase-negative 58 , besides species-specific nuc gene PCR. Also, PCR investigation to its enterotoxin gene presence (Table 8 ). All molecular characterization was performed at the Animal Health Research Institute, Dokki, Giza, Egypt.

Antimicrobial susceptibility testing

The disc diffusion technique 63 using a bacterial suspension with turbidity standards of 0.5 McFarland and Muller Hinton agar plates (OXOID) using 16 antibiotics of different classes: CEZ (cefazolin), CF (Cefoxitin), CAZ (Ceftazidime), AMX (Amoxicillin), AT (Azithromycin), TMP-SMZ (Sulpha/Trimethoprim),CMP (Chlorampheniol), IMI (Imipenem), CIP (Ciprofloxacin), GEN (Gentamycin), CL (Clindamycin), K (Kanamycin), MUP (Mupirocin), P (Penicillin), V (Vancomycin) and TE (Tetracycline), and the diameter of inhibition zone was estimated as described by Christensen et al. 64 .

Biofilm formation

The Micro titer plate method for recognizing biofilm formation was performed following the scheme mentioned by Christensen et al. 64 . By using a micro-ELISA auto- reader at a wavelength of 570 nm, the optical density of the adherent stained biofilm was measured, and the results are determined according to the following equations, as shown in Table 9 .

Detection of integron

The selected pan-drug-resistant strain was selected for detection of integron using hep 35 and hep 36 genes, which encoded a conserved region of the integrase gene 61 and then for detection of integron 1 cassette 62 using PCR-specific primers as shown in Table 8 . It was carried out at the Animal Health Research Institute, Dokki, Giza, Egypt.

Preparation and characterization of silver nanoparticles 65

Preparation of silver nanoparticles.

Using starch as a means of decreasing and stabilizing the obtained Ag-NPs, high throughput production was used to prepare the Ag-NPs solution 66 . In summary, 2 g of raw rice starch (WINLAB laboratory chemicals Co., U.K.) was progressively dissolved with stirring in an alkaline solution pH 11 (0.3 g sodium hydroxide; Sigma-Aldrich, Germany). The mixture was continuously stirred until the starch was completely dissolved. Concurrently, 100 ml of deionized water were used to dissolve 0.5 g of silver nitrate [99.99%; Sigma-Aldrich, Germany]. At 60 °C, the silver nitrate solution was gradually added to the starch solution while being stirred. The color progressively changed from a murky white to a transparent yellow hue, which is indicative of Ag-NP production. The final concentration of Ag-NPs solution was 400 µg/ml.

Characterization of silver nanoparticles

Initially, ultraviolet visible spectroscopy (UV–Vis; TG 80; Germany) was used to measure the absorbance of Ag-NPs. The findings indicate that Ag-NPs have a robust absorption peak at 408 nm, but starch molecules do not exhibit any discernible band that could be linked to surface plasmon excitation. Transmission electron microscopy (TEM; JEOLJEM-1230; Japan) was used to examine the particle form and distribution of starch-mediated Ag-NPs. The resulting particles verified the high capacity of starch to reduce silver ions and stabilize the generated Ag-NPs, with a small spherical size of approximately 40 nm and a well-distributed size. After centrifuging the high throughput Ag-NPs solution for 60 min at 4480 × g, Ag-NPs was obtained as powder. An ambient Siemens D500 X-ray diffractometer (30 mA and 40 kV) with a copper tube was used to examine the elemental analysis of the powdered Ag-NPs using X-ray diffraction (XRD). Ag-NPs demonstrated a highly crystalline face-centered cubic architecture, as corroborated by the strong peaks seen in the XRD at 2θ = 37.88°, 44.27°, 64.43°, and 77.35°. The Ag-NPs (220), (200), (311), and (111) planes are the indexes for the diffraction peaks.

Determination of S. aureus susceptibility/resistance to Ag-NPs

After preparing 0.5 McFarland’s standard from S. aureus in Brain heart infusion broth (BHI), A Muller Hinton agar (MH) plate was swabbed with the bacteria suspension, and the plate was then incubated for 30 min. Different concentrations of Ag-NPs diluted in de-ionized water were added to wells in the agar with adequate spacing between wells, and then plates were incubated for 20 h at 37 °C. According to CLSI, the lowest concentration of Ag-NPs that kills 100% of the initial bacterial population (showing no colony on MH agar after 20 h of incubation at 37 °C) is known as the minimum bactericidal concentration (MBC). After detecting the minimum bactericidal concentration of Ag-NPs, the tested bacteria, separately, were inoculated onto brain heart infusion broth and then centrifuged to collect a higher number of pellets. The collected pellets were adjusted to be incubated with Ag-NPs colloidal solution concentration to match the minimum bactericidal concentration of Ag-NPs for 2.5, 10, and 25 min, respectively, to be examined by SEM for morphological changes determination 67 , 68 .

Bacterial growth inhibition test: 69 , 70

One colony from the pan drug-resistant strain was inoculated in brain heart infusion broth (BHI) (Sigma Aldrich) and kept for 24–48 h in a shaking incubator (144 rpm). BHI broth was used to dilute the bacterial culture to adjust the count to 10 6 CFU/ ml. An equal volume of each concentration of nanoparticles diluted solution (400, 200, 100, 50, 25, 12.5, 6.25, 3.12 µg/ml) was added to the same volume of a bacterial strain to obtain a 5 × 10 5 CFU/ ml total volume. Following overnight incubation in a shaking incubator under the same conditions described above, 100 µl of each sample was streaked in a static incubator to track the bacterial growth curve. The experiment was carried out in triplicate.

Determination of the minimum inhibitory concentration (MIC) 71

Double-fold serial dilution of silver nanoparticles was added to a culture holding 10 6 CFU/ ml and incubated as before. On Muller Hinton agar plates, 100 µl of each was then smeared. The smallest double-fold serial solution with little to no bacterial growth is the minimal inhibitory concentration (MIC).

Scanning electron microscope

All the electron microscopy investigation was carried out at the Faculty of Science, Alexandria University. The morphological measurement of nanoparticles was conducted using SEM (Vega Tescan, USA) that measures the size of nanoparticles 72 .

Ultrastructure observations

By using SEM (scanning electron microscope) at the Faculty of Science, Alexandria University, the particle size, shape of silver nanoparticles and the morphological changes in treated bacterial cells with nanoparticles were determined.

Table 10 showed the primer pairs for REP-PCR amplification and conditions. After electrophoresis in a submerged agarose gel (1.5%), the size of the amplified fragments was recognized 73 . Computer software was used to analyze the data. The REP-PCR and the analysis of the data was carried out at the Animal Health Research Institute, Dokki, Giza, Egypt.

Statistical analysis

Data were collected in a spreadsheet Excel, SPSS version 22 was used. Monte Carlo Sig. (2-sided) and Kendall's tau_b correlation were applied to predict the association between independent variables and outcomes, between qualitative variables. Logistic regression was applied to predict the risk factors (odds ratio) of independent variables and outcomes. Dendrogram Ward linkage was used to rescale distance cluster combine.

Data availability

Data is provided within the manuscript.

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Elghazaly, E.M., Torky, H.A. & Tawfik, R.G. Effect of silver nanoparticles and REP-PCR typing of Staphylococcus aureus isolated from various sources. Sci Rep 14 , 21997 (2024). https://doi.org/10.1038/s41598-024-71781-w

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Received : 25 April 2024

Accepted : 30 August 2024

Published : 23 September 2024

DOI : https://doi.org/10.1038/s41598-024-71781-w

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