a thesis on covid 19

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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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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.

PubMed Disclaimer

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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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

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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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Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes

1 Department of Infectious Disease, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan Shandong, China

2 Department of Infectious Disease, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan Shandong, China

Daniel Q. Huang

3 Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore

4 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

5 Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford California

Hongli Yang

Natasha tang sook yee, chuanli liu, sanjna nilesh nerurkar, justin chua ying kai, margaret li peng teng.

6 Division of Infectious Disease, The Third People's Hospital of Shenzhen, Shenzhen Guangdong, China

7 Department of Internal Medicine, School of Medicine, Shenzhen University, Shenzhen Guangdong, China

John A. Borghi

8 Lane Medical Library, School of Medicine, Stanford University, Stanford California

Linda Henry

Ramsey cheung.

9 Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto California

Mindie H. Nguyen

Associated data.

The data that supports the findings of this study are available in the supplementary material of this article.

Coronavirus disease 2019 (COVID‐19) has become a pandemic, but its reported characteristics and outcomes vary greatly amongst studies. We determined pooled estimates for clinical characteristics and outcomes in COVID‐19 patients including subgroups by disease severity (based on World Health Organization Interim Guidance Report or Infectious Disease Society of America/American Thoracic Society criteria) and by country/region. We searched Pubmed, Embase, Scopus, Cochrane, Chinese Medical Journal, and preprint databases from 1 January 2020 to 6 April 2020. Studies of laboratory‐confirmed COVID‐19 patients with relevant data were included. Two reviewers independently performed study selection and data extraction. From 6007 articles, 212 studies from 11 countries/regions involving 281 461 individuals were analyzed. Overall, mean age was 46.7 years, 51.8% were male, 22.9% had severe disease, and mortality was 5.6%. Underlying immunosuppression, diabetes, and malignancy were most strongly associated with severe COVID‐19 (coefficient = 53.9, 23.4, 23.4, respectively, all P < .0007), while older age, male gender, diabetes, and hypertension were also associated with higher mortality (coefficient = 0.05 per year, 5.1, 8.2, 6.99, respectively; P = .006‐.0002). Gastrointestinal (nausea, vomiting, abdominal pain) and respiratory symptoms (shortness of breath, chest pain) were associated with severe COVID‐19, while pneumonia and end‐organ failure were associated with mortality. COVID‐19 is associated with a severe disease course in about 23% and mortality in about 6% of infected persons. Individuals with comorbidities and clinical features associated with severity should be monitored closely, and preventive efforts should especially target those with diabetes, malignancy, and immunosuppression.

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1. In this systematic review and meta‐analysis of 212 studies involving 281,461 individuals with COVID‐19 from 11 countries/regions, the overall mortality was 5.6%, and 22.9% had severe disease. Immunosuppression, diabetes, malignancy and abdominal pain were strongly associated with severe disease.
2. Close to one‐quarter of individuals with COVID‐19 develop a severe disease course, and individuals with clinical features associated with severity should be monitored closely.

Abbreviations

1. introduction.

On 11 March, the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID‐19) outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) a pandemic. 1 Currently, the deadly COVID‐19 has no effective therapy or vaccine. In addition, the signs of having COVID‐19 are nonspecific or can be absent, adding challenges to disease control and prevention. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 As COVID‐19 rapidly spreads, many available data sources were based on case series or small cohorts, limiting their conclusions.

The current pandemic has highlighted the marked variation in patient demographics, access to healthcare, healthcare infrastructure, and preparedness among regions, and these, in turn, have significantly impacted outcomes. 10 These factors are important for health policy, not only for the current pandemic but for future global events. Therefore, the aim of this systematic review and meta‐analysis aims was to elucidate regional variations in baseline clinical characteristics, presentation, and factors associated with outcomes in COVID‐19 patients including subgroup analysis by country/region and by disease severity.

2.1. Search strategy and selection criteria

Following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement for the conduct of meta‐analyses of observational studies ( http://www.prisma-statement.org/ ), two researchers independently performed the literature search, extracted the data and assessed for study quality. This study protocol was submitted for PROSPERO registration.

We searched Pubmed, Embase, Scopus, the Cochrane Library, the Chinese Medical Journal as well as the BioRxiv, MedRxiv, Preprints databases from 1 January 2020 to 6 April 2020 using search strategy developed in collaboration with an experienced medical librarian (JAB). Detailed search strategy and selection criteria are described in the Appendix Methods section. Briefly, for Pubmed, we used the search term (2019‐nCoV OR 2019‐nCoV OR COVID‐19 OR SARS‐CoV‐2 OR [wuhan AND coronavirus] AND 2019/12[PDAT]:2030[PDAT]). Original research articles were included if they fulfilled the following criteria: (a) laboratory‐confirmed COVID‐19 and (b) if the study provided information about clinical features and outcomes of COVID‐19. We excluded animal studies, review articles, and consensus documents. Exclusion criteria were as follows: (a) the study was a review article, letters to the editor, clinical trial, animal study, comments, consensus documents; (b) the study did not focus on patients with COVID‐19 or diagnosis was unclear. If the patients came from the same hospital with overlapping cases, we only selected the publication containing greatest number of cases.

We developed a case report form to screen and extract data and a specific database to house all study data. Quality assessment was performed using the Newcastle‐Ottawa scale (NOS) which comprised of three domains: selection, comparability, and outcome. 11 The risk of bias was assessed based on a total score of nine stars such that studies with seven to nine stars had a low risk of bias, four to six stars had a moderate risk of bias, and one to three stars were considered as a high risk of bias. Articles were initially screened by titles and abstract, followed by full article review to identify eligible studies. Discordant results were resolved by discussion between the two reviewers and/or by consulting a third senior researcher.

2.2. Statistical analysis

We used a random‐effects model to estimate pooled means or proportions of relevant COVID‐19 clinical characteristics and/or outcomes such as demographic data, medical history, exposure history, underlying comorbidities, symptoms, signs, laboratory findings (complete blood count, blood chemistry, coagulation test, liver and renal function, electrolytes) and chest computed tomography (CT) scans, complications (eg, adult respiratory distress syndrome), and death in the overall and selected populations. We assessed for heterogeneity using the Cochran Q‐statistic and I 2 ‐statistic. Estimates with P value of less than .05 in Q‐statistic and I 2 ≥ 50% were considered to have significant heterogeneity. The following subgroup analyses were performed to determine the source of the observed heterogeneity: age, gender, country/region, sample size, and quality assessment score. We performed meta‐regression to assess factors associated with severe disease which is based on the WHO Interim Guidance Report criteria for severe pneumonia. 12 , 13 In addition, we identified studies that reported outcomes in special subgroups including the pediatric age group and pregnant women. However, the data from pediatric and pregnant individuals were included only in subgroup analysis and not in the main meta‐analysis or in the meta‐regression. We utilized Egger's test to assess for publication bias. As a sensitivity analysis, we performed analysis without data from preprints studies, low‐quality studies, or studies with less than 10 patients. In addition, to assess whether there is a relationship between one or more covariates with mortality proportion, the direction, and magnitude of the relationship, we performed meta‐regression with the dependent variable being the logit transformation of mortality proportion (formula: in (p/(1‐p) = intercept + coefficient × (the value of covariate). 14 A P value of less than .05 suggests the presence of statistically significant relationship between the covariate and mortality proportion, the positivity or negativity of the coefficient denotes the direction of the relationship, and the numerical value of the coefficient corresponds to the magnitude of the relationship. All statistical analyses were conducted using the meta‐packages in R statistical software (version 3.6.3).

A total of 6007 articles were retrieved and 5795 were excluded as per our exclusion criteria (Figure 1 ). We analyzed data from 212 studies conducted in 11 countries/regions (Mainland China: 180, United States: 8, South Korea: 6, Singapore: 3, Italy: 3, Taiwan: 3, UK: 2, Hong Kong: 2, Canada: 1, Japan: 1, Vietnam: 1, and more than one country/region 2). Of these 212 articles, 164 were peer‐reviewed publications, and 48 were in preprint form; 161 were in English, and 51 were in Chinese. The details of study characteristics for each of the included 212 studies are summarized in Table S1. A total of 188 studies were included in the overall analysis, while 258 studies that provided data exclusively for special populations (eg, pediatric, pregnant, severe COVID‐19 vs nonsevere COVID‐19) were included only in subgroup analyses (Figure 1 ). Some studies provided data for more than one analysis, hence the sum added up to be greater than 212.

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Flow chart of systematic literature search and screening for studies of COVID‐19. COVID‐19, coronavirus disease 2019

The quality assessment for each paper is included in Table S1. The average NOS score was 7, with 122 studies being of high quality, 90 of medium quality, and none of low quality.

3.1. Geographic distribution and demographic characteristics

The majority of study patients came from the United States (n = 223 862; 79.5%) followed by Mainland China (n = 24 605; 8.7%), Italy (n = 24 105; 8.6%), and South Korea (n = 7848; 2.8%). The individual study sample sizes ranged from 1 to 149 082 (Table S1).

The pooled mean age in the overall cohort was 46.7 years (95% confidence interval [CI]: 42.8‐50.5) using data from 88 studies (n = 8908) (Table 1 ) and was similar between patients from Mainland China and outside Mainland China ( P = .1) (Table S2A), and within Mainland China between those from Hubei vs outside Hubei ( P = .08) (Table S2B).

Demographic and clinical characteristics of COVID‐19 patients

	Number (N) of studies	Number (n) of study population	Value	95% CI
Demographics
Mean age, y	88	8908	46.7	42.8‐50.6
Male (%)	168	17 1689	51.9	50.4‐53.2
Female (%)	164	17 1034	48.95	47.5‐50.4
Clinical presentation
Onset
Time from illness onset to first hospital admission, d	26	3508	5.5	4.6‐6.4
Incubation period, d	7	746	5.3	4.5‐5.99
General
Fever (%)	156	15 921	78.8	76.2‐81.3
Chills (%)	28	4430	15.7	12.3‐19.7
Fatigue (%)	99	13 680	32.2	28.0‐36.6
Myalgia (%)	78	10 728	21.3	18.1‐24.9
Malaise (%)	39	2526	37.9	29.5‐47.1
Respiratory
Cough (%)	119	12 782	53.9	50.0‐57.7
Expectoration (%)	61	8748	24.2	21.0‐27.8
Rhinorrhea (%)	43	6072	7.5	5.7‐9.6
Chest pain (%)	32	3512	9.0	6.2‐13.1
Shortness of breath (%)	82	11 205	18.99	15.7‐22.8
Gastrointestinal
Vomiting (%)	48	7484	4.7	3.8‐5.8
Abdominal pain (%)	23	3350	4.5	3.3‐6.2
Diarrhea (%)	94	12 149	9.5	7.8‐11.5
Anorexia (%)	30	3610	13.99	10.4‐18.5
Nausea (%)	38	5599	6.96	5.3‐9.1
Neurological
Dizziness (%)	24	2350	9.4	7.1‐12.4
Headache (%)	76	12 382	9.7	8.3‐11.3
Comorbidities
Malignancy (%)	47	8733	3.3	2.6‐4.3
Chronic heart disease (%)	52	82 217	7.9	4.9‐12.6
Chronic renal disease (%)	32	81 471	2.8	1.2‐6.1
Chronic lung disease (%)	30	78 691	4.0	2.3‐6.95
Chronic liver disease (%)	32	79 525	3.3	1.7‐6.3
Diabetes (%)	71	84 469	10.2	7.4‐13.9
Hypertension (%)	74	9937	19.4	17.3‐21.6
Clinical course and outcomes
Intensive care unit	39	80 487	10.96	6.6‐17.6
Mortality (%)	86	52 808	5.6	4.2‐7.5
Shock (%)	13	2985	4.3	2.3‐7.9
Mechanical ventilation (%)	36	6152	7.1	4.5‐11.0
Hepatic injury (%)	13	77 331	7.9	2.6‐21.7
Renal injury (%)	17	77 679	3.6	1.2‐10.1
Cardiac injury (%)	10	1417	9.4	4.5‐18.8

Abbreviations: CI, confidence interval; COVID‐19, coronavirus disease 2019.

The overall pooled proportion of males was 51.8% (95% CI: 50.4‐53.2) (168 studies, Table 1 ) and was similar when stratified by within vs outside Mainland China, within Mainland China Hubei vs outside Hubei, and within Hubei Wuhan vs outside Wuhan (all P > .05) (Tables S2A and S2B).

3.2. Diagnosis method, incubation period, and mode of transmission

Of the 212 studies, 190 (89.6%) studies used polymerase chain reaction (PCR) alone to diagnose COVID‐19, one study (0.5%) used a serum antibody test alone, nine (4.3%) studies used a combination of chest CT and PCR tests, one study (0.5%) used a combination of chest CT and antibody tests, and one study (0.5%) used a combination of PCR, chest CT, and antibody tests. The remaining 10 (4.7%) studies did not specify how COVID‐19 was diagnosed. Studies from all countries apart from Mainland China relied on PCR alone to diagnose COVID‐19.

The pooled mean incubation period in the overall cohort was 5.3 days (95% CI: 4.5‐6.0) (seven studies, 746 patients, Table 1 ). The incubation period was shorter in studies outside Mainland China (4.0 days, 95% CI: 3.0‐5.1) vs 6.0 days (95% CI: 4.7‐7.3) in Mainland China ( P = .02) (Table S2A). However, there was only one study that provided data for incubation period outside of Mainland China. Within Mainland China, there was no difference in the incubation period when stratified by Hubei vs outside Hubei ( P = .4) (Table S2B).

A total of 161 studies (n = 17 648) provided data for mode of transmission. The most common mode of transmission was travel‐related (58.1%, 95% CI: 51.1‐64.8), followed by close contacts (43.1%, 95% CI: 37.2‐49.2), and finally community spread (27.4%, 95% CI: 18.4‐38.7).

3.3. Clinical symptoms, disease presentation, and course

The pooled mean time from illness onset to first hospitalization was 5.5 days (95% CI: 4.6‐6.4) (26 studies, 3508 patients, Table 1 ). This duration was shorter in studies outside Mainland China (3.3 days, 95% CI: 2.2‐4.5) compared to within Mainland China (5.7 days, 95% CI: 4.8‐6.7) (Table S2A) ( P = .002). Within Mainland China, the time from illness onset to hospitalization was longer in Hubei province (7.5 days, 95% CI: 5.7‐9.2) compared with outside Hubei province (4.5 days, 95% CI: 3.8‐5.3) ( P = .003) (Table S2B).

The most common symptom was fever (78.8%, 95% CI: 76.2‐81.3), followed by cough (53.9%, 95% CI: 50.0‐57.7) and malaise 37.9% (95% CI: 29.5‐47.1). In contrast to other respiratory viral infections, the proportion of individuals with rhinorrhea was low (7.5%, 95% CI, 5.7‐9.6). With regards to gastrointestinal symptoms, the proportion of individuals with diarrhea was 9.5% (95% CI: 7.8‐11.5), while abdominal pain and vomiting were less common (4.5%, 95% CI: 3.3‐6.2 and 4.7%, 95% CI: 3.8‐5.8, respectively).

The pooled proportion of patients admitted to intensive care unit (ICU) was 10.96% (95% CI: 6.6‐17.6) (39 studies, 80 487 patients, Figure 2A ), without significant differences among the included countries/regions ( P = .3) (Figure 2A ). However, within Mainland China, there was a higher proportion of individuals admitted to ICU in Hubei province vs outside Hubei province (15.6%, 95% CI: 10.8‐21.95 vs 8.1%, 95% CI: 4.8‐13.4; P = .04) (Figure 2A and Table S2B); and within Hubei province, there were more patients admitted to ICU in Wuhan vs outside Wuhan (16.6%, 95% CI: 10.96‐24.3 vs 8.8%, 95% CI: 5.7‐13.1; P = .03).

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Object name is JMV-93-1449-g001.jpg

A, Proportion of COVID‐19 patients requiring intensive care unit. B, Proportion of COVID‐19 patients requiring mechanical ventilation. C, Proportion of COVID‐19 patients with severe disease. D, COVID‐19 mortality. COVID‐19, coronavirus disease 2019

The pooled proportion of patients that required mechanical ventilation from 36 studies (6152 patients) was 7.1% (95% CI: 4.5‐11.0) (Figure 2B and Table 1 ). Within Mainland China, this proportion was higher in Hubei province compared with outside Hubei (10.8%, 95% CI: 6.5‐17.2 vs 4.5%, 95% CI: 3.0‐6.7; P = .01) (Figure 2B and Table S2B). Within Hubei province, 10.8% (95% CI: 6.5‐17.2) of patients from Wuhan required mechanical ventilation compared to 4.4% (95% CI: 2.9‐6.5) in Hubei patients from outside Wuhan city ( P = .01).

Overall, 22.9% (95% CI: 13.3‐36.5) of COVID‐19 patients had severe disease (35 studies, 79 170 patients) as defined by WHO Interim Guidance Report or Infectious Disease Society of America/American Thoracic Society criteria (Figure 2C ), 12 , 13 with no statistically significant difference between Mainland China vs outside Mainland China patients ( P = .3). However, within Mainland China, the proportion of severe disease within Hubei was higher than that outside of Hubei (36.1%, 95% CI: 28.1‐44.9 vs 17.3%, 95% CI: 14.1‐21.1; P < .0001).

3.4. Demographic characteristics and comorbidities

Individuals with severe disease were significantly older (60.4 years, 95% CI: 57.8‐63.1) compared to those without severe disease (44.6 years, 95% CI: 42.8‐46.3), P < .0001 (Table S3B). There were significantly more males in the severe group (60.8%, 95% CI: 57.2‐64.2) compared with the nonsevere group (47.6%, 95% CI: 44.9‐50.4), P < .0001. Compared to patients without severe disease, severe COVID‐19 patients were more likely to have hypertension (35.9%, 95% CI: 31.2‐40.7 vs 14.5%, 95% CI: 11.5‐18.1; P < .0001), diabetes (20.1%, 95% CI: 16.6‐24.2 vs 6.2%, 95% CI: 3.2‐11.9; P = .0005) as well as chronic renal disease ( P = .01), chronic lung disease ( P = .02), chronic heart disease ( P = .002), and malignancy ( P = .03).

3.5. Symptoms, signs, and laboratory characteristics

Shortness of breath was present in about half (48.96%, 95% CI: 39.3‐58.7) of severe cases compared with only 13.6% (95% CI: 9.8‐18.5) of nonsevere cases, P < .000 (Table S3B). Chills ( P < .0001), abdominal pain ( P = .01) and dizziness ( P = .02) were also more common among those with severe disease.

Pooled mean AST ( P < .0001), ALT ( P = .006), urea ( P = .02), C‐reactive protein ( P < .0001), neutrophil count ( P = .0007) and white blood cell count ( P = .003) were higher in severe disease compared with nonsevere disease (Table S3C). Conversely, lymphocyte count was lower in severe disease ( P < .0001).

In general, shock and organ injuries were more common in severe cases compared to nonsevere ones (26.5%, 95% CI: 15.95‐40.7 vs 1.2%, 95% CI: 0.4‐3.1; P < .000 for shock; 14.1%, 95% CI: 6.6‐27.8 vs 1.96%, 95% CI: 0.5‐7.5; P = .01 for cardiac injury).

3.6. Meta‐regression: factors associated with severe COVID‐19

Meta‐regression of multiple study‐level clinical and laboratory characteristics showed statistically significant correlation between several factors and disease severity (Table 2 ). The clinical characteristics strongly associated with severity were immunosuppression (coefficient: 53.9, 95% CI: 31.3‐76.4; P < .0001), abdominal pain (coefficient: 24.7, 95% CI: 17.4‐31.94; P < .0001), malignancy (coefficient 23.4, 95% CI: 9.9‐36.94; P = .0007) and diabetes (coefficient: 23.4, 95% CI: 14.99‐31.7; P < .0001). The complete list of variables analyzed by meta‐regression is found in Table S4A.

Significant factors associated with severe COVID‐19 illness a

	Coefficient	95% CI
Diabetes	23.4	14.99‐31.7	<.0001
Malignancy	23.4	9.9‐36.9	.0007
Cerebrovascular disease	19.6	2.6‐36.6	.02
Hypertension	5.1	1.1‐9.1	.01
Immunosuppressed	53.9	31.3‐76.4	<.0001
Time from illness onset to first hospital admission, d	0.4	0.1‐0.6	.0008
Shortness of breath	5.4	4.1‐6.7	<.0001
Vomiting	11.4	0.2‐22.7	.05
Abdominal pain	24.7	17.4‐31.9	<.0001
Fatigue	1.7	0.3‐3.0	.01
Chest pain	4.5	1.8‐7.1	.001
Nausea	8.8	0.2‐17.4	.05
Respiratory failure	1.4	0.6‐2.3	.001
Lymphocyte count, g/L	−2.2	−4.3‐(−0.2)	.04
Neutrophil count, g/L	0.6	0.2‐0.9	.0008
Albumin, µmol/L	−0.2	−0.3‐(−0.1)	.0009
C‐reactive protein, mg/L	0.02	0.01‐0.04	.007

Abbreviations: ATS, American Thoracic Society; CI, confidence interval; COVID‐19, coronavirus disease 2019; IDSA, Infectious Disease Society of America; WHO, World Health Organization.

3.7. Mortality outcome

The overall pooled mortality was 5.6% (95% CI: 4.2‐7.5) (Figure 2D ) using data from 86 studies and 52 808 patients (number of studies: Mainland China: 73, Italy: 3, United States: 3, Singapore: 2, South Korea 2, UK 1, Vietnam 1, Global 1).

Mortality varied significantly amongst individual countries/regions, 5.3% (95% CI: 3.7‐7.6) in Mainland China, 14.3% (95% CI: 4.2‐39.2) in Italy, 4.4% (95% CI: 0.7‐23.6) in United States, and 0.9% (95% CI: 0.7‐1.1) in South Korea, P < .0001. However, there was no significant mortality difference when stratified by Mainland China (5.3%, 95% CI: 3.7‐7.6) vs non‐Mainland China (5.6%, 95% CI: 2.6‐11.8), P = .90.

3.8. Clinical characteristics of COVID‐19 survivors vs nonsurvivors

Nonsurvivors were almost 20 years older (68.9 years, 95% CI: 66.8‐71.0) than survivors (50.7 years, 95% CI: 46.6‐54.8), P < .0001 (Table S3A), and there were no differences in the proportion of males ( P = .3). Nonsurvivors compared to survivors were more likely to have hypertension (44.9%, 95% CI: 34.4‐55.8 vs 23.8%, 95% CI: 19.3‐29.0; P = .0003) and diabetes (24.8%, 95% CI: 18.7‐32.0 vs 13.9%, 95% CI: 10.5‐18.1; P = .003), as well as malignancy ( P = .01), chronic heart disease ( P = .003), chronic renal disease ( P = .03), and chronic lung disease ( P = .04). However, there were no significant differences between the nonsurvivor and survivor group in terms of presenting symptoms or organ injuries except for kidney injury (29.98%, 95% CI: 20.6‐41.5 vs 4.5%, 95% CI: 0.8‐21.7; P = .02) (Table S3A).

3.9. Meta‐regression: factors associated with COVID‐19 mortality

Meta‐regression of multiple study‐level clinical and laboratory characteristics showed statistically significant correlation between several clinical and laboratory factors and mortality (Table 3 ). Among baseline characteristics, age, male sex, hypertension, and diabetes were significantly associated with increased mortality. Clinical factors also significantly associated with mortality included pneumonia, kidney injury, shock, cardiac failure, and acute respiratory distress syndrome. Laboratory parameters significantly correlated with mortality included increased white cell count, neutrophil count, AST, ALT, creatinine, lactate dehydrogenase, procalcitonin, and C‐reactive protein (Table 3 ). Lymphocyte count and albumin were inversely correlated with mortality. The complete list of variables analyzed by meta‐regression is found in Table S4B.

Significant factors associated with COVID‐19 mortality

Factors	Coefficient	95% CI
Age	0.05	0.02‐0.08	.0005
Male	5.1	2.4‐7.9	.0002
Diabetes	8.2	2.4‐13.99	.006
Hypertension	6.99	3.3‐10.7	.0002
Shortness of breath	2.8	1.0‐4.6	.002
Fever	2.9	0.2‐5.7	.04
Cough	2.1	0.2‐4.1	.03
Chills	5.8	2.8‐8.9	.0002
Fatigue	2.5	0.5‐4.5	.01
Malaise	2.7	0.7‐4.8	.0098
Diarrhea	3.4	0.01‐6.9	.05
Pneumonia	11.7	5.9‐17.5	<.0001
Shock	23.3	13.7‐32.9	<.0001
Kidney injury	14.4	9.0‐19.8	<.0001
Cardiac failure	6.2	2.3‐10.1	.002
Adult respiratory syndrome	6.1	4.5‐7.6	<.0001
Respiratory failure	2.5	0.4‐4.6	.02
Total white blood cell count, g/L	0.3	0.07‐0.6	.01
Lymphocyte count, g/L	−2.1	−3.3‐(−0.8)	.001
Neutrophil count, g/L	0.5	0.3‐0.8	<.0001
Alanine aminotransferase, U/L	0.06	0.01‐0.10	.01
Aspartate aminotransferase, U/L	0.03	0.01‐0.05	.002
Total bilirubin, µmol/L	0.2	0.01‐0.4	.04
Albumin, g/L	−0.4	−0.5‐(−0.2)	<.0001
Creatinine, μmol/L	0.03	0.01‐0.05	.0006
Lactate dehydrogenase, U/L	0.01	0.00‐0.02	.007
Procalcitonin, ng/mL	2.1	0.7‐3.5	.004
C‐reactive protein, mg/L	0.04	0.02‐0.05	<.0001
Blood urea nitrogen, mmol/L	0.4	0.09‐0.6	.009
Creatinine kinase, U/L	−0.02	−0.03‐(−0.005)	.003
Prothrombin time, s	0.4	0.01‐0.8	.04
Antibiotic usage	4.1	2.9‐5.4	<.0001
Corticosteroids usage	4.3	2.6‐6.1	<.0001
Immunoglobulin	3.6	0.7‐6.4	.01
Continuous renal replacement therapy	18.7	5.4‐32.0	.006
Extracorporeal membrane oxygenation	24.7	0.7‐48.6	.04
Intensive care unit	5.1	3.0‐7.2	<.0001

3.10. Pediatrics

A total of 14 studies involving 2786 patients aged 0.55 to 18 years provided data for this analysis. The pooled mean age was 4.6 years (95% CI: 1.1‐12.8), and 50.3% (95% CI: 43.99‐56.7) were male. Twelve studies (296 individuals) provided data for mortality. The pooled mortality was 3.8% (95% CI: 1.8‐8.1), 8.1% (95% CI: 2.8‐21.3) required admission to ICU, and 5.99% (95% CI: 2.5‐13.7) required mechanical ventilation.

3.11. Pregnant women

Analysis of nine studies comprising of 305 pregnant COVID‐19 patients demonstrated a pooled proportion of patients requiring ICU admission of 6.9% (95% CI: 2.5‐18.0). The pooled proportion of preterm delivery was 26.8% (95% CI: 13.99‐45.2) and of fetal loss was 4.6% (95% CI: 1.9‐10.5). Finally, among a small sample of 43 patients from six studies, the pooled proportion of obstetric complications (eg, pre‐eclampsia, premature rupture of membranes, gestational hypertension) was 51.7 (95% CI: 36.9‐66.3).

Sensitivity analyses were performed for the clinical characteristics and outcomes of COVID‐19 individuals, excluding studies that were (a) in preprint form and (b) studies with less than 10 individuals (Table S5A‐C). The results from the sensitivity analyses yielded similar results to the main analyses. As all included studies were of at least moderate quality, sensitivity analyses excluding low‐quality studies were not performed.

There was considerable heterogeneity among the studies for the overall and subgroup results (all I 2 statistic >98.00). Egger's test was not suggestive of significant publication bias in the analysis for mortality ( P = .6) but was significant in the analysis for severity ( P < .001).

4. DISCUSSION

In this large and comprehensive systematic review and meta‐analyses involving 212 studies and 281,461 individuals from 11 countries/regions, we found that COVID‐19 patients had a mean age of about mid 40's, equally distributed among the sexes, and without significant demographic differences among the countries/regions analyzed. We estimated a severe disease rate of about 23% and a mortality of about 6%, with the main variation toward the highest severe disease rate for Wuhan, China (38%), and highest mortality for Italy (14%) followed by Wuhan and Hubei (about 11%). Among those with severe disease, the pooled mean age was 60 years and more than half (61%) were male. In addition, severe COVID‐19 patients were more likely to have existing comorbidities such as diabetes, malignancy, immunosuppression, and hypertension, highlighting the special need for disease prevention and control in these high‐risk populations.

The pooled mean time from the onset of symptoms to hospitalization was 5.48 days and was notably longer in Mainland China compared to outside of Mainland China (about 6 vs 3 days). Within Hubei province, the time to hospitalization was 7.5 days compared to 4.5 days outside of Hubei, which may be related to the overwhelmed healthcare resources closer to the epicenter of the outbreak. We also noted significant differences in ICU admission within China with utilization rates being about 16% to 17% in Wuhan compared to 8% to 9% outside of Wuhan and Hubei. Wuhan and Hubei also had two times higher rates of mechanical ventilation than outside these areas (about 11% vs 5%). Together, these data suggest the presence of delayed diagnosis and care leading to more severe disease at presentation likely due to the overwhelmed healthcare resources at the onset of this pandemic, which advocates for local preparedness to prevent severe disease progression and mortality.

With regards to presenting symptoms as potential predictors for disease progression, abdominal pain, an infrequent symptom, were notably strongly associated with severe COVID‐19 disease. Those who present with abdominal pain should be more closely monitored for rapid decompensation. Similarly, patients with low lymphocyte and albumin levels may have a more severe course of disease. We hypothesize that people at most risk for dying may be the ones that are malnourished, as reflected in low albumin. This hypothesis is probable especially when we look at countries such as the United States where clusters of COVID‐19 cases appearing in elderly nursing homes carry a disproportionate number of deaths. 15 Therefore, this is an area that needs further research especially as the world's population continues to age 16 and as the pandemic marches to resource‐limited regions where malnutrition may be more common.

Among children, the mortality was nearly 4%, with 8% requiring ICU admission and 6% requiring mechanical ventilation. This pooled data may be limited by the small numbers of included patients, and we note that only 1.8% of patients in a recent study were admitted to the ICU. 17 Similarly, the pooled data show that among pregnant individuals, 7% were admitted to the ICU, fetal loss occurred in 5%, and half develop obstetric related complications. However, our pooled data were based on only 43 patients drawn from six studies and should be interpreted with caution, but these findings warrant further investigation.

Our study is not without its limitations. Due to the lack of age group studies, we were unable to perform any subanalyses by age groups other than the pediatric population. As the proportion of individuals with mild or asymptomatic COVID‐19 infection may be much higher than expected, the pooled data we report is likely to be an over‐estimate as most of the data comes from hospital‐based studies. With the pandemic constantly evolving, a recent study was published after our study completion showing a 21% mortality in New York City. 18 Another limitation of our study is the fact that we included case reports to avoid missing potentially important data for this new pandemic, but case report data may bias towards the extremes or atypical. However, we performed sensitivity analyses that excluded studies with less than 10 patients and found similar results. Part of the differences in death rates among the different studies and countries/regions could also be attributed to how COVID‐19 deaths are reported. Some countries may only be reporting deaths that are felt to be a direct cause of COVID‐19 and not just deaths occurring in COVID‐19 patients. Therefore, a universal definition of which deaths should be reported needs to be developed. Nonetheless, these data are important for each respective country to determine their death rate in comparison to others when developing their own policies addressing COVID‐19. In addition, the majority of studies included in our meta‐analysis are hospital‐based and/or tertiary care center‐based studies, so our data may not be generalizable to affected patients outside of this setting, and further studies focusing on less severe community patients are needed. Last, as the pandemic spreads across the globe, additional data have become available for other regions not well represented in this study; therefore, more updated review and meta‐analysis providing data for more regions of the world are needed.

In conclusion, we provide a large systemic review and regarding the clinical features and associations with severe COVID‐19 disease. These data can inform healthcare providers and policy decision‐makers as to how best to identify and monitor patients at most risk for the development of severe COVID‐19 as well as to identify vulnerable populations where special measures to prevent COVID‐19 transmission may be needed.

AUTHOR CONTRIBUTIONS

Guarantor of article: Mindie H. Nguyen; study concept and study supervision: Mindie H. Nguyen; study design: Jie Li, Daniel Q. Huang, Ramsey Cheung, and Mindie H. Nguyen; manuscript drafting: Jie Li, Daniel Q. Huang, Linda Henry, Ramsey Cheung, Mindie H. Nguyen; manuscript edition and final approval: all authors; data analysis: Biyao Zou, Jie Li, Daniel Q. Huang, and Mindie H. Nguyen; data collection and/or data interpretation: all authors.

CONFLICT OF INTERESTS

Ramsey Cheung has received research support for Gilead Sciences. Mindie H. Nguyen has received research support from Gilead, BMS, and Janssen, and has served as an advisory board member or consultant for Dynavax, Gilead, Alnylam, BMS, Novartis, Spring Bank, and Janssen. Other authors have no disclosures.

Supporting information

Li J, Huang DQ, Zou B, et al. Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes . J Med Virol . 2021; 93 :1449‐1458. 10.1002/jmv.26424 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Jie Li and Daniel Q. Huang contributed equally to this article.

[Correction added after online publication on 10 September 2020: Duplicate table 4 has been removed completely]

DATA AVAILABILITY STATEMENT

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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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https://doi.org/10.1371/journal.pone.0258133.t001

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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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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Read these 12 moving essays about life during coronavirus

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

by Alissa Wilkinson

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

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

The Vox guide to navigating the coronavirus crisis

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

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

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

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

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

A syllabus for the end of the world

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

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

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

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

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

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

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

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

What day is it today?

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

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

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

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

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

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

Vox is starting a book club. Come read with us!

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

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

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

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

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

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

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

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

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Frontiers in Psychology
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Coronavirus Disease (COVID-19): The Impact and Role of Mass Media During the Pandemic

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The outbreak of coronavirus disease 2019 (COVID-19) has created a global health crisis that has had a deep impact on the way we perceive our world and our everyday lives. Not only the rate of contagion and patterns of transmission threatens our sense of agency, but the safety measures put in place to contain ...

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

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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.

Please note that you may opt to include a COVID-19 Thesis Impact Statement for examination and remove it from your library copy but you cannot do the reverse. A COVID-19 Thesis Impact Statement cannot be included in your library copy if it wasn’t included in the examination copy.

Content of a COVID-19 Thesis Impact Statement

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.

Format of a COVID-19 Thesis Impact Statement

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.

Read full article

ChatGPT: Disruptive or Constructive?

Thursday, Jul 18, 2024 • Jeremiah Valentine : [email protected]

What is Chat GPT?

ChatGPT is a popular emerging technology using Artificial Intelligence. GPT stands for Generative Pre-trained Transformer, which describes an AI program that looks for patterns in language and data learning to predict the next word in a sentence or the next paragraph in an essay. The website has a friendly interface that allows users to interact with AI in a n efficient conversational tone . ChatGPT provides another opportunity for students, instructors, researchers, workers, and others to find practical solutions to everyday and complicated problems.

At the root of this conversation is Artificial Intelligence. I plan to explore applicable uses of AI and ChatGPT in the classroom , entrepreneurial potential uses, and applications in industry .

Everyday Uses of Artificial Intelligence

The use of Artificial I ntelligence varies based on the user and their end goal. While many individuals will use certain programs or websites to meet specific objectives , many companies and apps have begun to utilize this emerging technology to better meet their customer's needs.

Duolingo is a popular foreign language learning application that I use to supplement my Spanish studies . The app uses Artificial Intelligence to assess users' knowledge and understanding as they interact with the program , thus streamlining users learning outcomes.

As another example, Khan Academy is a free online resource that helps teachers and students learn any level of math or other grade school topics for free. They have created Khanmigo , using AI. The model acts as a tutor that helps work through a problem while not directly providing the answer. It can assist in writing an essay or solving a complex math problem step by step.

These everyday applications continue a trend of companies implementing this new technolog y into students and teachers' lives . . This new AI technology also allows business professionals to enhance aspects of their processes.

Entrepreneurs, A.I. and the Advantages

While AI already provides companies and organizations with new ways to interact with and better support their customers, AI could also provide emerging industries and entrepreneurs with new paths to business success.

According to Entrpreneur.com, most businesses currently use AI for customer service purposes , however , AI could also help entrepreneurs create effective spreadsheets cataloging useful data with accuracy that can be incredibly specific or broad. Specifically with customer service, AI can quickly find what a customer needs and solve their problems efficiently. It could also analyze how effective marketing campaigns are influencing customers’ purchases.

As I researched for more information about this topic, I found an article in The Journal of Business Venturing Insights published in March 2023, sharing different techniques business students can use ChatGPT as an asset to generate entrepreneurial business pitches. The article titled “ The Artificially Intelligent Entrepreneur” written by Cole Short, an Assistant Professor of Strategy at Pepperdine University, and Jeremy C. Short, a UTA alumni and Professor at the University of North Texas at Denton, showcased different elevator pitch scenarios.

Students and entrepreneurs study CEOs who have impacted an industry dynamically; the CEO's mentality is an asset . I had the opportunity to question Dr. Jeremy Short on how he arrived at the initial question of using AI as a CEO archetype business consultant. An archetype is a symbol, term, or pattern of behavior which others have replicated or emulated.

He responded, “ We used this existing framework and selected a CEO from each archetype and used ChatGPT to create elevator pitches, social media pitches, and crowdfunding pitches. The strength of ChatGPT is based largely on the creativity of the prompt, which is where we aim as authors.”

CEO Archetypes and Prompt Engineering

ChatGPT allows the user to understand the archetypes of successful CEOs and collaborate with entrepreneurial styles. These archetypes are accessible options to consult with AI. Let ’ s break down different CEO archetypes students used during this study:

Creator CEOs are typically serial entrepreneurs and serve during the growth stages of developing new businesses. These individuals are risk takers recognizing opportunities that others don ’ t see. Elon Musk, CEO of Tesla, SpaceX, and Twitter is the creator archetype.

Transformer CEOs are created by climbing the ladder of a successful business and adding new ideas . They have a firm understanding of the company's culture and work to dramatically change the company, separating it from missteps in the past. Indra Nooyi CEO of PepsiCo is the transformer archetype.

Savior CEOs rescue businesses on the verge of failure with disciplined actions, unique experience and insights they forge a successful path forward for declining businesses. Lisa Su, CEO of AMD is the savior archetype.

ChatGPT was prompted to write an elevator pitch in the style of the previously listed CEOs.

The response for Elon Musk included language about “ building” a product with “ cutting-edge technology.”

Indra Nooyi ’s response included phrases like “ the world is changing” and making “ a positive impact in the world.”

Lisa Su's response produced a pitch speaking about being “ accountable, tough and disciplined” with an emphasis on “ a strong focus on efficiency and performance.”

However, I believe these positions can help entrepreneurs develop their own successful business practices; creating a product your former employer could use to gain an advantage over the competition is disruptive. B uying a company on the brink of bankruptcy that has been mismanaged is a scenario entrepreneurs have explored and practiced .

Prompt engineering is the description of a task AI can accomplish , with instructions embedded in the input. Using prompt engineering, users can fine-tune their input to achieve a desired output incorporating a task description to guide the AI model.

Conversation around ChatGPT and Artificial Intelligence

I asked Dr. Short about how students could use this technology as an asset that guides their learning and, additionally, how instructors can use this as well. He spoke about an assignment he is currently using in his classes. “ Chat GPT might be valuable in helping create a recipe for material that students can then refine. For example, in my social entrepreneurship class students create crowdfunding campaigns for either DonorsChoose , a platform that caters to public school teachers or GoFundMe , a service which allows a variety of project types to a larger userbase . I plan on students using ChatGPT to create a ‘rough draft’ to show me so I can see how they refine their responses for their particular campaigns this upcoming fall.” Th is approach allows students to take advantage of popular technology in a constructive way.

The journal article provided some notable conclusions about ChatGPT , i ncluding “ quality control is essential when using automated tools; a hallmark of success for large language models is their vast associative memory, this strength can also be a weakness. Specifically, models such as OpenAI’s GPT-3.5 and GPT-4 are capable of confidently generating “ hallucinated” output that appears correct but, it is incorrect or completely fabricated. ChatGPT serves as an emerging tool that can efficiently and flexibly produce a range of narrative content for entrepreneurs and serve to inspire future research at the intersection of entrepreneurship and AI.” ChatGPT ’s limitations and potential applications are continually being explored.

Industry Application

After researching various applications of AI, I spoke with Dr. George Benson, Professor and Department Chair of the Department of Management at The University of Texas at Arlington, about AI and ChatGPT from an industry perspective. His research focuses on Artificial Intelligence with Human Resource Management .

Dr. Benson told me that Artificial Intelligence is being invested heavily by human resource departments who are looking to automate hiring practices. Specifically, he mentioned “ HR is using this as a market opportunity. AI is a useful tool to sift through potential applicants by scanning their resumes for qualifications and experiences. Allowing professionals to hire applicants faster.”

This application allows the technology to handle low-level tasks, but the results generated are being handed to a human to review and act on. He spoke about the potential of A.I. “ There are a lot of unknowns, but the technology is new and getting better.” Looking towards the future, technology is already being applied in different ways . These applications are being explored in the classrooms of UTA as well.

A group of Alumni discuss rankings in a conference room.

Exploration of AI at UTA

The College of Business conduct ed a survey to understand the faculty’s attitude towards A I in the classroom. It was a part of the “Teaching with Chat GPT” workshop on Friday February 9 th , which focus ed on how to integrate Chat GPT and other AI platforms into teaching .

Dr. Kevin Carr, a Clinical Assistant Professor of Marketing at UTA, was a part of the workshop ; he currently teaches Advanced Business Communication . I talked to him about the purpose of the workshop and what he hopes to gain from the group's sessions.

Dr. Carr explained "The point of the workshop is designed to give faculty ideas for instruction and to develop classroom activities to work with students . Our goal for th e workshop is to introduce Artificial Intelligence as a teaching tool for faculty, including showing what AI can do potentially in the classroom. We are going to be very open to faculty’s direction, in terms of ongoing discu ssions and meetings.”

Personal Take

Artificial Intelligence or Chat GPT , in my view, is another useful tool in the toolbox of technology. It will take the air out of certain industries, and it will change jobs, yet every major technological advancement has the potential to do so. The automobile was considered radical, the use of plastic, computers in the workplace, and alternative energy have been impactful on society.

Alternative energy was headlined as the end of oil use. The automobile changed the way cities were formed and led to the creation of a national highway system. Society has always found a way to adapt and overcome major technological innovations, artificial intelligence is not any different.

AI is the technology of tomorrow. It reminds me of something Dr. George Benson said , “ It's cool software that is a sophisticated search engine.” Google, one of the most popular search engines, reshaped the internet, as you search for resources, it is a natural starting point. AI and ChatGPT are an evolution, for students it is a tremendous resource consulting a CEO archetype, creating business pitches, and most importantly shaping the future .

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Introduction

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Social and interactional norms

Recommendations and conclusions

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

Recommendation 2: intelligently balance online and offline ways of relating

Recommendation 3: build stronger and sustainable localised communities

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

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Study selection

Data collection process

Quality assessment in individual reviews

Synthesis of results

Managing overlapping systematic reviews

Characteristics of included reviews

Population and study designs

Systematic review findings

Clinical symptoms

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Therapeutic possibilities

Laboratory and radiological findings

Quality of evidence in individual systematic reviews

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BMC Infectious Diseases

Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes

Daniel Q. Huang

Hongli Yang

John A. Borghi

Linda Henry

Mindie H. Nguyen

Abbreviations

2.1. Search strategy and selection criteria

2.2. Statistical analysis

3.1. Geographic distribution and demographic characteristics

3.2. Diagnosis method, incubation period, and mode of transmission

3.3. Clinical symptoms, disease presentation, and course

3.4. Demographic characteristics and comorbidities

3.5. Symptoms, signs, and laboratory characteristics

3.6. Meta‐regression: factors associated with severe COVID‐19

3.7. Mortality outcome

3.8. Clinical characteristics of COVID‐19 survivors vs nonsurvivors

3.9. Meta‐regression: factors associated with COVID‐19 mortality