THE RE VIEW

| Aim

This scoping review aims to synthesis the psychological impacts of social isolation amongst older

adults during COVID-19 and +reviews the benefits and barriers of online interventions used to

combat so- cial isolation.

| Design

This scoping review followed a methodological framework devel- oped by Arksey and O’Malley

(2005) and refined by Levac et al. (2010). The first stage involved identifying research questions,

which guided the objectives of this review. The scoping review questions are as follows: What are

the psychological impacts amongst socially isolated older adults during COVID-19? What are the

existing online interventions provided for older adults during COVID-19?

| Search methods

The second stage involved identifying relevant studies. A systematic search was performed in the

following electronic databases: China National Knowledge Infrastructure (CNKI), PubMed, EMBASE,

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO,

and Web of Science. The research team collaborated with a librarian to develop a three-step

extensive search strategy as recommended by the Joanna Briggs Institute (JBI) manual for evidence

synthesis (Campbell et al., 2020).

The first step included an initial search using pre-specified key- words and Medical Subject

Headings (MeSH) terms ‘Social Isolation’, ‘Quarantine’, Older Adult*’ and ‘COVID-19’ in PubMed.

The addi- tional keywords and relevant MeSH terms generated were used in the second step of the

search according to the different syntax rules of the rest of the databases (Supplementary File S1).

The third step involved performing a hand search from the reference lists of se- lected studies and
World Health Organization (WHO) publications. An additional search of grey literature was carried

out from Scopus, ProQuest Dissertation and Google Scholar.

Stage three involved compiling and uploading all identified ci- tations into a reference manager,

EndNote X9 (The EndNote Team, 2013). Duplicates were removed. Two reviewers (NR and CH)

first screened the titles and abstracts independently based on the inclu- sion and exclusion criteria

and later retrieved the full text to be as- sessed in detail. Disagreements in the process were

discussed in the research team.

| Eligibility criteria

The inclusion criteria were (1) participants of any gender, aged 55 years old and above, living alone

in the community or in long-term care facilities, or socially isolated, (2) participants can either be

phys- ically healthy or have any pre-existing medical conditions during the time of the study, (3)

studies that state or evaluate the psychologi- cal impact experienced by the participants, (4)

Interventional studies which address mental health issues in older adults during COVID-19,

(5) studies that include the context of the COVID-19 pandemic in any geographical location, (6)

study designs including qualitative, quan- titative, mixed-method study, case study, review,

commentary, dis- cussion paper. Only studies published from January 2020 onwards were included.

This scoping review considered sources of evidence from any existing literature that met the above

inclusion criteria. Included articles were only limited to English and Chinese language. The

justifications for the inclusion and exclusion criteria were pro- vided in Supplementary File S2.

| Quality appraisal

Seven JBI appraisal tools were selected based on the study design: JBI critical appraisal tool for case

report, text and opinion paper, analyti- cal cross-sectional studies, prevalence studies, qualitative

research, quasi-experimental, and Randomised Controlled Trials (Joanna Briggs Institute, 2017).
SANRA, the Scale for the Assessment of Narrative Review Articles, was used to assess the quality of

the included nar- rative reviews (Baethge et al., 2019). Two reviewers (NR and CH) conducted the

quality appraisal independently. Disagreements were settled in discussion with the third reviewer

(XVW).

| Data extraction

In stage four, two reviewers (NR and CH) developed a data chart form based on the research

questions. This draft charting table was piloted among five papers. After independently extracting

the data, we compared contents before making revisions to the chart form. The final key items of

information we extracted narratively from the included articles were the following: author(s), year

of publication, research aim, design and data collection, sample characteristics, in- tervention,

outcome measures, main findings.

| Synthesis

Finally, in the last stage, for quantitative studies, we looked at the findings and evaluated if it

supported the aim of the study. For ex- ample, Gaeta and Brydges (2020) reported 56.4% of

participants reporting feeling isolated and 36.0% reporting feeling lonely due to stay-at-home

orders during the pandemic. These results were re- viewed in the discussion and showed relevance

to the sub-theme. While qualitative data were analysed thematically and presented in a descriptive

manner under the following categories: (a) results of data extraction, (b) themes related to the

psychological impact faced by socially isolated older adults, interventions to tackle social isolation

and its barriers. Researchers used an inductive and seman- tic approach to familiarise with the

texts from the different studies before identifying common patterns and themes directly from the

information presented.
| RESULTS

| Search outcomes

The electronic databases search identified 2783 records, of which 1400 duplicated records were

removed. A hand search of the reference lists of the included papers and on WHO publications

yielded additional ten records, bringing the total to 1393 articles for review using the inclusion and

exclusion criteria. After 198 full texts were retrieved and screened, we identified the final 33

papers. The flow of articles was reported using the Preferred Reporting Items for Systematic

Reviews and Meta-Analysis (PRISMA) as shown in Figure 1 (Tricco et al., 2018).

Study characteristics

The 33 articles included a range of research designs as illustrated in Figure 1. The majority of

studies were conducted in the United States (n = 13), followed by Israel (n = 4), Spain (n = 2), the

United Kingdom (n = 1), Europe (n = 1), Italy (n = 1), Japan (n = 1), Netherlands (n = 1), Sweden (n =

1), France (n = 1) and Brazil (n = 1). One of the com- mentaries included perspectives from China,

Hong Kong, Italy and Australia while one of the narrative reviews included studies from Taiwan,

England, Scotland, Canada, Australia, Sweden, Netherland and the United States. The remaining four

articles did not mention where the studies were conducted as it was not relevant. Most of the

papers (n = 29) described older adults’ experiences and feel- ings, specifically the adverse

psychological turmoil and mental health issues they faced during social distancing measures.

Eleven papers either proposed online interventions to combat social iso- lation amongst older

adults or evaluated the benefits and barriers of those interventions. Out of the 33 articles, the

sample of older adults +was predominately from community settings, while only five articles

reported older adults from long-term care facilities. Six arti- cles reported samples from a mixture

of long-term care facilities and community setting. Table 1 describes the detailed characteristics of

the included studies.

| Quality appraisal

The overall appraisal of the articles was ranked based on the per- centage of "yes" scores to the

individual questions asked in each critical appraisal checklist. The risk of bias was ranked as high

when the study reached up to 49% of ‘yes’ scores, moderate for 50 to 69% of ‘yes’ scores, and low

for more than 70% of ‘yes’ scores (Melo et al., 2018; The Institute Joanna Briggs, 2014)

(Supplementary File S3). Out of 33 articles, 60% are of low risk. About 15% are of moderate risk,

while another 24% are of high risk. For the quality appraisal, agreement between reviewers was

high (average kappa score =0.86, p-value = <.00001). With COVID-19 as a relatively recent and new

topic, time has been a heavily limiting factor for any experimental study to be conducted. Hence,

text and opinion studies are a more common type of study design to research this emerging field.

The elements of the appraisal tool for textual or opinion-based reviews focus on authenticity of the

opinion, its source, and how both sides of the opinions are presented. These elements are more

universal and general and are likely to be easily fulfilled, resulting in low risk ratings (McArthur et

al., 2015). Since more than half of the included articles are of low risk, it gives a strong reason for

the quality assess- ment of articles to be reliable.

Discussion

To the best of our knowledge, this is the first study to investigate the effects of changes in the

working environment and study modality on the mental health status (anxiety, depressive

symptoms, stress-related factors, and resilience) and coping mechanisms of full-time nurses

engaging in part-time study.

Our survey revealed that most of the respondents were frontline nurses working in public sectors

(89.5%), with nearly one-third reporting symptoms of depression (29%) and more than half
reporting mild to severe levels of anxiety (61.3%) during the COVID-19 pandemic. These findings

were comparable with those of previous studies in mainland China [27] and the U.S. [28].

Meanwhile, the percentages of depression and anxiety among the general population in Hong Kong

[3] were lower than those of the study cohort in the current study as expected. These findings were

also consistent with those reported in a previous study in mainland China [29]. This was

particularly true when frontline nurses carried critical roles and responsibilities in fighting COVID-

19 in the healthcare settings. In facing these public health emergencies, frontline healthcare

workers during the COVID-19 pandemic were at risk of developing psychological distress and other

mental health symptoms. The sources of mental health burden are considered to be related to the

risk of infection, uncertainty, home quarantine and social isolation, high work demand and low

work control, physical exhaustion, sleep disruption, and weakened immune system due to high

levels of stress [30]. In addition to part-time study, the ever-increasing number of suspected and

confirmed cases have further contributed to the mental burden of this study cohort.

Our findings showed that the resilience score was significantly negatively associated with the level

of anxiety, which implies that resilience is associated with lower anxiety lev- els. This finding

agreed with previous research conducted during the COVID-19 pandemic, which demonstrated a

significant correlation between resilience and anxiety experienced by healthcare workers [31].

Resilience has also shown a protective effect on anxiety and mental health [32], with more

resilience indicating better mental health. Resilience reflects an individual’s ability to ‘bounce back’

in difficult circumstances [15], and it is vital to the ability to cope with a crisis, such as COVID-19. As

resilience can be developed [e33], it is necessary to develop interventions to promote resilience

among nurses to prevent or mitigate the occurrence of psychological distress during pandemic

situations. Nevertheless, our finding revealed that attendance at resilience workshops was not

significantly associated with anxiety or depression, although resilience itself was. This finding may

imply that attendance at a resilience workshop alone was inadequate to enhance resilience. Indeed,
a previous meta-analytic review [33] demonstrated that programs employing a one-on-one

delivery format were most effective, followed by the classroom-based group delivery format and

train-the-trainer and computer-based delivery formats. Thus, ways of building resilience should be

further explored and expanded to improve effectiveness.

Emerging evidence has shown that mindfulness is a contributing factor to resilience [ 34,35]. Thus,

interventions incorporating elements of mindfulness could increase resilience [36,37], mitigate

fatigue and burnout [38], and cultivate psychological well-being [39,40]. In the current survey,

nearly 40% of the respondents showed interest in the mindfulness-training workshops. It has been

suggesting that nursing programs incorporating resilience should be a regular part of training and

continuing education for frontline healthcare work- ers [41,42]. Future studies and courses at the

institutional level could adopt mindfulness training to build and sustain resilience, thereby

reducing psychological distress among frontline healthcare workers.

Exhaustion, a stress-related factor, significantly predicted the level of anxiety. This is supported by

studies conducted in Asia that have shown a correlation of psychological distress with exhaustion

[43,44]. These findings could be explained by the physical and psychological exhaustion that occur

as a result of work commitments and fear of COVID-19 infection. These frontline nurses failed to

have sufficiently full personal lives or effective methods to provide stress relief. It highlights the

need for academic institutes and orga- nizations to improve the stress levels and mental health of

frontline nurses during the pandemic by acknowledging and relieving their stress.

Interestingly, anxiety about the infection, another stress-related factor, was significantly positively

associated with the level of depression. This finding is consistent with those previous studies

conducted among the general population in Hong Kong [3] and healthcare professionals in South

Asian country [45], which demonstrated that people with depressive symptoms reported having a

significant fear of COVID-19. This fear may be attributed to the severity and unpredictable

trajectory of the disease, as well as information overload or misinformation about the pandemic
[45]. In addition, the fear of COVID-19 might possibly be worsened by the co-existence of

depression and anxiety disorder [46].

This study has several limitations. First, the respondents were full-time nurses who studied part-

time at a single institution, which affects the generalizability of the findings. Second, reverse

causality and reporting bias are possible due to the cross-sectional nature and self-reported

measurement. Third, the response rate of 32% reported in this study was relatively low; although it

was comparable to other online surveys, our survey may have been subject to response bias.

Moreover, respondents who chose to participate may not be representative of non-participating

individuals; for example, the non-participating individuals may not have direct experience of

COVID-19 or online learning as major stressors, or they may have been too stressed to respond. In

addition, other factors that were not related to work should be explored if they may account for the

self-report measures, and levels of anxiety and depression, such as personality traits, e.g.,

neuroticism, overestimation of threat; family issues, e.g., family members being unemployed, caring

children and elderly at home, parents being hospitalized, loss of loved ones; frequency of exposure

to social media, etc. Only with a complete account of the factors affecting levels of psychological

distress should a tailor-made intervention be considered, in which resilience training and

mindfulness may not be the most appropriate approach to be adopted. Although the adjusted

models demonstrated that part-time study was not significantly associated with the psychological

distress of this study cohort, the lack of a comparison group who was not having part-time study

might limit the generalization of the findings. In the future study, a comparison group should be

considered in order to assess if part-time study was a factor affecting levels of psychological

distress of the study population.

Conclusions

To conclude, licensed full-time practicing nurses undertaking part-time studies in higher education
appeared to have a mild level of anxiety on average. The resilience score and exhaustion were

significantly associated with anxiety, and anxiety about infection was significantly associated with

depression. Effective measures and interventions should be developed at the organizational level

and within the academic sector to alleviate the psychological distress experienced by licensed full-

time practicing nurses studying part- time in higher education in facing the pandemic.
ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has caused enormous psychological impact

worldwide. We conducted a systematic review and meta-analysis on the psychological and mental

impact of COVID-19 among healthcare workers, the general population, and patients with higher

COVID-19 risk published between 1 Nov 2019 to 25 May 2020. We conducted literature research

using Embase, PubMed, Google scholar and WHO COVID-19 databases. Among the initial search of

9207 studies, 62 studies with 162,639 participants from 17 countries were included in the review.

The pooled prevalence of anxiety and depression was 33% (95% con- fidence interval: 28%-38%)

and 28% (23%-32%), respectively. The prevalence of anxiety and depression was the highest

among patients with pre-existing conditions and COVID-19 infection (56% [39%-73%] and 55%

[48%- 62%]), and it was similar between healthcare workers and the general public. Studies from

China, Italy, Turkey, Spain and Iran reported higher-than-pooled prevalence among healthcare

workers and the general public. Common risk factors included being women, being nurses, having

lower socioeconomic status, having high risks of contracting COVID-19, and social isolation.

Protective factors included having sufficient medical resources, up-to-date and accurate

information, and taking precautionary measures. In conclusion, psychological inter- ventions

targeting high-risk populations with heavy psychological distress are in urgent need.

Introduction

The coronavirus disease 2019 (COVID-19) outbreak is posing a serious public health threat

worldwide. According to the World Health Organization (WHO), as of 1 June 2020, 6,040,609

confirmed cases and 370,657 deaths have been reported globally (World Health Organization,

2020). A recent large-scale study has shown that multi- faceted public health interventions are
temporarily associated with improved control of COVID-19 pandemic (Pan et al., 2020). However,

in addition to the physical health, the potential psychological and mental health impacted by the

COVID-19 pandemic should also be taken seriously. Although previous research has suggested that

the mental impact of a major disaster had a wider and longer effect on people compared to physical

injuries, mental health attracts far fewer personnel for planning and resources (Allsopp et al.,

2019).

Studies conducted on the psychological impact of previous infectious outbreaks, such as the

severe acute respiratory syndrome (SARS) that is similar to the COVID-19 pandemic, have found

heavy psychological burdens among healthcare workers and the general public such as anxiety,

depression, panic attacks, or psychotic symp- toms (Maunder et al., 2003; Xiang et al., 2020).

Healthcare workers who were quarantined, worked in SARS units, or had family or friends infected

with SARS, had considerably more anxiety, depression, frus- tration, fear, and post-traumatic stress

than those who had no such experience (Xiang et al., 2020; Wu et al., 2009). Similarly, many pub-

lished studies have assessed the psychological impact of COVID-19 and have also found high levels

of psychological distress.

A recent systematic review and meta-analysis has summarized the prevalence of depression and

anxiety among healthcare workers during the COVID-19 (Pappa et al., 2020). The re- view was

conducted at the early phase of the COVID-19 (before April 17th, 2020) and mainly included early

studies published in Asia (China, Singapore). After the publication of the review (Pappa et al.,

2020), many more studies from other countries (e.g. Italy, Spain, Iran, Israel) have been published

and some of these studies extended the study population from health- care workers to the general

public and patients with pre-existing conditions (e.g. cancer, psychiatry, epilepsy, type 2 diabetes)

or infected by COVID-19. A few studies have suggested that the psychological impact of COVID-19

may be different among healthcare workers, the general public and patients. Since the case number

of COVID-19 is still rapidly increasing in many countries, psychological disturbances may have
impacted and will continue to impact millions of people around the world. Understanding the

psychological impact from different populations and countries would provide theoretical basis for

the identification of high-risk people and designing interventions, as well as planning resources and

pro- mulgating national and governmental policies, which is of critical im- portance and public

health implication at a global level.

Therefore, we conducted the current systematic review and meta- analysis to assess the updated

psychological and mental impact of the COVID-19 pandemic among healthcare workers, the general

public and patients with pre-existing conditions or COVID-19. We searched on Embase, PubMed,

Google Scholar, and the daily updated WHO COVID- 19 database (World Health Organization,

2020). Our primary aim was to evaluate the psychological and mental impacts of COVID-19. Our

secondary aims was to explore factors associated with higher psycho- logical distress.

Discussion

Main findings

In the current systematic review and meta-analysis, we have ob- served an overall high

psychological impact of COVID-19 pandemic among healthcare workers, the general public, and

patients with pre- existing conditions or COVID-19. The most common indicators of psy- chological

impact reported across studies were anxiety and depression, and the respective prevalence was

33% (28%-38%) and 28% (23%- 32%). Patients with pre-existing conditions or COVID-19 had sig-

nificantly higher prevalence of anxiety and depression compared to healthcare workers and the

general public, and studies reported higher- than-pooled prevalence of anxiety and depression

among the latter two groups included studies conducted in China, Italy, Turkey, Spain and Iran.

Common risk factors of heavier psychological burden included being women, being nurses, having

high risks of contracting COVID-19, having lower socioeconomic status, social isolation, and

spending longer time watching COVID-19 related news; protective factors in- cluded having
sufficient medical resources, having up-to-date and ac- curate health information, and taking

precautionary measures.

In comparison with previous studies

Similar to the current study, a high prevalence of psychological symptoms, such as anxiety and

depression, has been reported in frontline medical workers, the general public, and patients with

sub- optimal health across outbreaks of Ebola, H1N1 and SARS (Maunder et al., 2003; Xiang et al.,

2020; Wu et al., 2009; Chew et al., 2020). Compared to the existing meta-analysis on psychological

impact of COVID-19 on healthcare workers from 13 Asian studies that reported a pooled prevalence

of 23.2% in anxiety and 22.8% in depression (Pappa et al., 2020), the current meta-analysis found a

similar prevalence of anxiety (26% [18%-34%]) and depression (25% [17%-33%]) among

healthcare workers. In addition, we extended the existing evidence by showing that the prevalence

of anxiety and depression was significantly higher among patients with pre-existing conditions or

COVID-19 in- fection compared to healthcare workers and the general public, which was supported

by a few studies that showed higher prevalence of psy- chological distress among patients

compared to healthy controls (Hao et al., 2020; Salari et al., 2020; Hao et al., 2020). Furthermore,

our studies showed that the prevalence of anxiety and depression was si- milar between healthcare

workers and the general public. A study conducted in China corroborated our finding by showing

that the pre- valence of anxiety and depression was similar between healthcare workers and the

general public (Ni et al., 2020); however, three other studies from China showed that healthcare

workers had higher pre- valence of anxiety and depression (Zhang et al., 2020; Huang and Zhao,

2020; Huang and Zhao, 2020). Among healthcare professionals working in the hospital, one study

showed that medical workers had higher psychological distress compared to administrative staff

(Lu et al., 2020), while another study showed that the psychological distress was higher among

non-medical workers in hospitals (Tan et al., 2020). Our findings suggested that patients with pre-
existing conditions and COVID-19 infection are at the highest risk of psychological distress and

should be targeted for psychological assessment and appropriate in- tervention.

The current review found that women and nurses had higher psy- chological distress compared to

men and doctors, respectively, which were consistent with previous findings that women and

nurses were more vulnerable to stress (Qiu et al., 2020, Sareen et al., 2013; Chou et al., 2014). In

addition, the current review also found that social isolation, financial security, and being more

susceptible to COVID-19 infections (have complications, older age) are associated with higher levels

of psychological distress. A recent review published on the Lancet Psychiatry corroborated with our

findings by showing that social iso- lation and loneliness are strongly associated with anxiety and

depres- sion, and populations with worse health or social inequality are more vulnerable to the

psychological distress of COVID-19 (Holmes et al., 2020). These findings highlighted the importance

to design interven- tions to target women, nurses, people with complications or older age, and

those with unstable income, whom may have higher psychological burden (Zhou et al., 2020).

Furthermore, we found that some factors, such as having sufficient medical resources, having up-to-

date and ac- curate health information, and taking precautionary measures could help decrease the

psychological impact among the general public. This highlighted the importance to ensure an

effective public health system at the governmental level and taking precautionary measures at the

personal level to decrease the mental impact.

The current study had important clinical and public health implications. First, we identified

high-risk population and risk factors of higher psychological distress that could be used for risk

stratification and the design of effective psychological interventions at both clinical and community

levels. Second, heavy psychological distress has been observed in the general public in various

countries that suffered from COVID-19 pandemic. Therefore, this finding underscored the im-

portance to implement and roll out psychological services and inter- vention programs across all

countries that have experienced COVID-19 pandemic. After the outbreak, China implemented rapid
psychological crisis intervention including releasing free self-help manual online (Bao et al., 2020),

and initiating 24-hour psychological hotlines and online consultations for the general public (Bao et

al., 2020) and healthcare workers (Zhou, 2020; Jiang et al., 2020; Zhang et al., 2020). In other

countries that suffered from COVID-19 pandemic at a later stage such as Korea, Singapore and Italy,

psychological support and interventions have also been prepared and rolled out to take care of

high-risk po- pulations during the COVID-19 pandemic (D’Agostino et al., 2020; Jung et al., 2020; Ho

et al., 2020). Third, since most countries around the world are currently prioritizing their medical

resources for the con- tainment of COVID-19 and the treatment of patients with COVID-19, there

may be limited resources available for psychological services and interventions. Therefore,

improving knowledge, awareness, and self- coping strategies are critical in the current situation. A

prior study has found that 50.4% of study participants had accessed psychological re- sources

through books or media, and 17.5% had sought counseling or psychotherapy (Kang et al., 2020). In

addition, the study also found that people with mild or lower disturbances preferred to obtain such

services from media sources, while those with heavier burdens ex- pressed their needs to seek

services directly from professionals (e.g. psychologists, psychiatrists) (Kang et al., 2020). This

finding suggested that psychological screening could be conducted among people, and triaged

therapies could be delivered to people with different levels of psychological impacts. Future studies

are warranted to evaluate the effectiveness of these interventions and the feasibility to scale up to a

larger population.

Strengths and limitations

Compared to the last systematic review and meta-analysis that comprised 13 studies from Asian

countries (n=33,062) (Pappa et al., 2020), the current meta-analysis included more studies (62

studies from 17 countries) with a much bigger sample size (n=162,639). In addi- tion, we

conducted comprehensive literature search in multiple im- portant databases, and the results of the
current study had important clinical and public health implication globally. However, several lim-

itations merit consideration. First, the current review included studies using different instruments

to measure psychological impacts (anxiety, depression, and others). However, since no study

utilized standardized clinical interviews for diagnosis, it is not known whether the presence of an

actual disorder exist. In addition, the outbreak of COVID-19 was observed in China first and then

subsequently in other countries; therefore, the majority of the included studies were conducted in

China (65%). Although we included studies from 17 countries, the sampling bias may still exist as

papers from many other countries may not have been published yet. Moreover, we only included

publications in English language, which may have brought publication bias. However, the limitation

in language could also ensure the quality of the included articles. Furthermore, all quantitative

studies were cross-sectional sur- veys or cohort studies with short follow-up duration; therefore,

long- term mental health implications and how these base rates of mental health symptoms

compare to other time periods cannot be inferred from these studies.

In conclusion, the COVID-19 pandemic has caused heavy psychological impact among medical

workers and the general public. Psychological interventions identifying and targeting people with

heavy psychological burdens are in urgent need. Future studies are warranted to design and

evaluate the effectiveness of psychological interventions.